DEMENTIA GATEWAY DIFFICULT SITUATIONS
Difficult situations 9 Antipsychotic medication and dementia Key messages
If the behaviours cause the person significant
Research indicates that people with dementia have
distress, or involve risks to the person or
been prescribed antipsychotic medication too
readily, and best practice guidelines now
recommend a considerable reduction in their use.
Antipsychotic medication can have unpleasant
People living with dementia will experience
and dangerous side effects for people with
changes in their behaviour and mental processes
dementia, making daily life much more difficult
Even when a person is withdrawn, we should
never treat them as if they're not there.
Why prescribe antipsychotic medication for a
frighteningly, they may believe that someone or something is trying to harm them. This is known as a 'paranoid delusion'.
The changes in the brain caused by dementia affect the way a person makes sense of what's going on around them. For
Some people with dementia experience psychotic symptoms,
example, a person with dementia might not recognise where
although hallucinations are more likely to be something the
they are living. Each person with dementia will respond and
person sees rather than hears. It may be thought that
behave differently in this situation. One person may find it
someone is experiencing delusions when actually they have
impossible to relax and will walk around, perhaps for a long
misinterpreted what is going around them, for example the
time, to try to get their bearings. Another person may
person believes that someone has stolen their money
become frightened and shout angrily because things aren't
because they don't remember where they put it.
where they expect them to be or they don't recognise the
Hallucinations and delusions are more common in some
person who is trying to help them have a bath. Somebody
types of dementia than others. People who have Dementia
else may ask questions about where they are and when they're going to go home over and over again in
with Lewy bodies (DLB), for example, are quite likely to
to understand what's happening to them. If the person's
experience the same visual hallucinations over and over again because of the way this type of dementia affects the
behaviour appears to be causing them significant distress,
and particularly if there is a risk of the person harming themselves or others, sometimes a doctor will prescribe
Antipsychotic medication was first prescribed to treat the
psychotic symptoms that some people with dementia experience, although they quickly began to be used to treat a
wider range of what are sometimes called 'behavioural and psychological symptoms in dementia' (and shortened to
People who live with severe mental health problems, such as
BPSD). These include aggression, agitation, restlessness,
schizophrenia, experience what are called 'psychotic
depressed mood, anxiety as well as the more severe
symptoms'. People with dementia can experience psychotic
difficulties such as hallucinations or delusions.
symptoms too. Hallucinations are an example of a psychotic symptom: hallucinations involve seeing, hearing, tasting,
Different types of antipsychotic medication
smelling or feeling something that isn't actually there. The most common type of hallucination is hearing voices, or what
Antipsychotic medication was developed to be prescribed to
is called an 'auditory hallucination'.
people of working age experiencing a psychotic condition like schizophrenia. These drugs weren't developed to be
Another type of psychotic symptom is a 'delusion', which
prescribed to older people or people whose brains are
means that a person holds very unusual beliefs about
themselves or those around them. A person may believe that they are God or another religious figure for example. More
Older types of antipsychotics are called 'typical'
speak clearly or understand what is being said to them, to
antipsychotics or major tranquillisers. They include
eat and drink or even sit or stand up comfortably.
thioridazine, haloperidol and stelazine; they are not licensed
People who know or care for the person may not realise that
for the use of people with dementia and are rarely prescribed
the drug is causing these changes and may think that the
person's dementia has worsened. Sometimes, there is relief
Newer types of antipsychotics are called 'atypical'
that the person's behaviour has become less challenging,
antipsychotics. These include risperidone and olanzapine
although their needs remain unmet and their wellbeing is
and, since being available from the mid-1990s, increasingly
were prescribed for people with dementia. In the late 2000s, this began to change with the publication in 2009 of a major
report from the Department of Health into antipsychotics for
Antipsychotic medication can make people, especially older
people with dementia, which questioned their heavy use.
people, ill. They can cause dehydration and water retention,
Further, in 2011 the Alzheimer's Society has published best
they can increase the likelihood of chest infections or cause
practice guidelines pressing for a much more considered use
heart problems. These effects make people more vulnerable
of antipsychotic medication for people with dementia.
to other illnesses, for example if people become dehydrated,
Risperidone is now the only drug licensed for very cautious
they are more likely to develop urine infections.
use with people with dementia, and then only in situations involving ongoing aggression for up to six weeks, with the
The newer antipsychotics like risperidone and olanzapine
person being very closely monitored for ill-effects.
tend to cause milder and less troublesome side effects, although these drugs carry an increased risk of stroke for
Problems with the use of antipsychotics for people with
Studies estimate that there are at least 1,800 extra deaths
dementia include their unpleasant and disabling side effects.
each year among people with dementia as a result of them
Older people are more likely to experience these side
taking antipsychotics, and that the likelihood of premature
death increases if people take these drugs for months or years rather than weeks (Department of Health 2009).
Antipsychotic medication can make the person feel very drowsy or cause their arms, legs and head to move without
People who have Dementia with Lewy bodies generally do
them meaning to, or make their body go very stiff or tremble.
not benefit from antipsychotics. They may cause all the
Not surprisingly, these effects can make it very hard for a
effects above with no benefit. If people with dementia are
person who already has difficulties as a result of their
experiencing hallucinations, it's essential to consider
dementia to maintain their current abilities, for example,
alternative responses (see the feature on
going to the toilet or dressing themselves. Taking
antipsychotic medication may make it difficult for someone to
The Alzheimer's Society (2011) published best practice guidelines to accompany the call for action. In general, it
suggests that services ensure that people with dementia have their medication reviewed regularly and that any
Antipsychotics can be useful to help someone manage the
introduction of a new drug is considered very carefully. Most
severe symptoms of a condition like schizophrenia, if they
importantly, if someone's behaviour begins to challenge
have this in addition to dementia. A low, short-term dose of
others, antipsychotics should NOT be the first course of
an antipsychotic can be useful if someone's behaviour is
action. Rather, the person's health care should be thoroughly
presenting a high risk, while other ways of meeting the
reviewed and close attention given to meeting their social
person's needs are explored and put into practice.
and psychological needs. For people already prescribed
When a range of non-medical interventions have been tried
antipsychotics, it may be possible to work in partnership with
without success, a proportion of people with dementia will
the GP or psychiatrist to reduce or stop the dose, while
experience less distress and disturbance if they take
working to make sure that the environment, care approach,
occupations and relationships with other people are
In situations where a person with dementia wants to stay at
home and the person caring for them wants them to
When a strategy for reducing the use of antipsychotics is
continue, the needs of both parties should be considered.
rolled out across a service, there can be a dramatic increase
Carefully monitored use of antipsychotics may enable
in the levels of physical and emotional well-being enjoyed by
everyone involved to have a better night's sleep, so feel
the people with dementia, and a corresponding increase in
much more able to manage the demands of the day, for
the satisfaction experienced by the staff (Baker 2009).
What can care teams do to reduce the use of antipsychotics?
In summer 2011, the Dementia Action Alliance - a group of
Factsheet 408. London: Alzheimer's Society.
organisations committed to improving dementia care - put
out a national 'call for action' asking all services providing
care for people with dementia to consider whether
antipsychotics are actually benefitting each individual who is
taking them. The primary aim of the call to action is to reduce
the number of people with dementia taking antipsychotics,
Baker, C. (2009) 'Introducing PEARL: Rewarding good
given that research estimates that about 30 per cent of
practice in dementia care', Journal of Dementia Care, vol 18,
people with dementia taking them could either stop or reduce
their dose without any ill-effects (Alzheimer's Society 2011).
independent report by Professor Sube Banerjee. London:
Social Care Institute for Excellence
Address for correspondence: Yan Lai, MM Clinical Investigation Department of CardiologyShanghai East HospitalTongji University School of MedicinePhosphoprotein Phosphorylation IndexImproves Clinical Outcome in PatientsWith Clopidogrel ResistanceXiao-dong Wang, MD; Dai-fu Zhang, MM; Shao-wei Zhuang, MD; Yan Lai, MMDepartment of Cardiology, Shanghai East Hospital, Tongji University School
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