Don’t use antipsychotics as the first choice to treat behavioral symptoms of dementia, avoiding prescription before careful evaluation and removal of precipitating factors.

Don’t use antipsychotics as the first choice to treat behavioral symptoms of dementia, avoiding prescription before careful evaluation and removal of precipitating factors.

Type of practice

Drugs

Age

Adult, Geriatric

Topic Area

Neurology

People with dementia often exhibit behavioral symptoms such as agitation, aggression, anxiety, irritability, depression, apathy and psychosis. In this context, antipsychotic medicines are often prescribed, but they often provide limited and inconsistent benefits, with possible severe side effects (increased likelihood of strokes and mortality, parkinsonism or other extrapyramidal symptoms, falls, fractures, sedation, confusion, cognitive worsening, weight gain and urinary tract disturbances).
Antipsychotic drugs should only be used for the treatment of agitation or psychosis in patients with dementia when symptoms are severe, dangerous, and/or cause significant distress to the patient. Identifying and addressing causes of behavior change (including infections, pain, constipation, environmental factors like noise or temperature), securing patients, mobilization, reducing discomfort and general functions assistance, can make drug treatment unnecessary. If a risk/benefit assessment favors the use of an antipsychotic, treatment (preferring atypical antipsychotics) should be initiated at a low dose and titrated up to the minimum effective dose and duration.

Sources

1. Yunusa I., Alsumali A., Garba A.E., Regestein Q.R., Eguale T. Assessment of Reported Comparative Effectiveness and Safety of Atypical Antipsychotics in the Treatment of Behavioral and Psychological Symptoms of Dementia A Network Meta-analysis. JAMA Netw Open. 2019 Mar 1;2(3):e190828
2. The 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. doi: 10.1111/jgs.15767
3. Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA. 2017 Sep 26;318(12):1161-1174. doi: 10.1001/jama.2017.12067.
4. Reus VI, Fochtmann LJ, Eyler AE, Hilty DM, Horvitz-Lennon M, Jibson MD, Lopez OL, Mahoney J, Pasic J, Tan ZS, Wills CD, Rhoads R, Yager J. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. Am J Psychiatry. 2016 May 1;173(5):543-6. doi: 10.1176/appi.ajp.2015.173501.
5. Richter T, Meyer G, Möhler R, Köpke S. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev. 2012 Dec 12;12:CD008634

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Attention. Please note that these items are provided only for information and are not intended as a substitute for consultation with a clinician. Patients with any specific questions about the items on this list or their individual situation should consult their clinician.