Antipsychotic medication and dementia

Why prescribe antipsychotic medication for a person with dementia?

The changes in the brain caused by dementia affect the way a person makes sense of what’s going on around them. For example, a person with dementia might not recognise where they are living. Each person with dementia will respond and behave differently in this situation. One person may find it impossible to relax and will walk around, perhaps for a long time, to try to get their bearings. Another person may become frightened and shout angrily because things aren’t where they expect them to be or they don’t recognise the person who is trying to help them have a bath. Somebody else may ask questions about where they are and when they’re going to go home over and over again in an attempt to understand what’s happening to them. If the person’s 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.

It has become clear that people with dementia as a whole are at higher risk of potentially serious adverse effects from antipsychotic medication.

Professor Sube Banerjee, in The use of antipsychotic medication for people with dementia: Time for action (Department of Health, 2009)

What are psychotic symptoms?

People who live with severe mental health problems, such as schizophrenia, experience what are called ‘psychotic symptoms’. People with dementia can experience psychotic symptoms too. Hallucinations are an example of a psychotic symptom: they involve seeing, hearing, tasting, smelling or feeling something that isn’t actually there. The most common type of hallucination is hearing voices, or what is called an ‘auditory hallucination’.

Another type of psychotic symptom is a ‘delusion’, which 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 frighteningly, they may believe that someone or something is trying to harm them. This is known as a ‘paranoid delusion’.

Psychotic symptoms and dementia

Some people with dementia experience psychotic symptoms, although hallucinations are more likely to be something the person sees rather than hears. It may be thought that someone is experiencing delusions when actually they have misinterpreted what is going around them, for example the person believes that someone has stolen their money because they don’t remember where they put it.

Hallucinations and delusions are more common in some types of dementia than others. People who have dementia with Lewy bodies (DLB), for example, are quite likely to experience the same visual hallucinations over and over again because of the way this type of dementia affects the brain.

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 BPSD). These include aggression, agitation, restlessness, depressed mood, anxiety as well as the more severe difficulties such as hallucinations or delusions.

Different types of antipsychotic medication

Antipsychotic medication was developed to be prescribed to people of working age experiencing a psychotic condition like schizophrenia. These drugs weren’t developed to be prescribed to older people or people whose brains are damaged by dementia. Older types of antipsychotics are called ‘typical’ antipsychotics or major tranquillisers. They include thioridazine, haloperidol and stelazine; they are not licensed for the use of people with dementia and are rarely prescribed now.

Newer types of antipsychotics are called ‘atypical’ antipsychotics. These include risperidone and olanzapine 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 people with dementia, which questioned their heavy use. Further, in 2011 the Alzheimer’s Society published best practice guidelines pressing for a much more considered use of antipsychotic medication for people with dementia. Risperidone is now the only drug licensed for very cautious use with people with dementia, and then only in situations involving ongoing aggression for up to six weeks, with the person being very closely monitored for ill-effects.

Unpleasant side effects

Problems with the use of antipsychotics for people with dementia include their unpleasant and disabling side effects. Older people are more likely to experience these side effects.

Antipsychotic medication can make the person feel very drowsy or cause their arms, legs and head to move without them meaning to, or make their body go very stiff or tremble. Not surprisingly, these effects can make it very hard for a person who already has difficulties as a result of their dementia to maintain their current abilities, for example, going to the toilet or dressing themselves. Taking antipsychotic medication may make it difficult for someone to speak clearly or understand what is being said to them, to eat and drink or even sit or stand up comfortably.

People who know or care for the person may not realise that the drug is causing these changes and may think that the person’s dementia has worsened. Sometimes, there is relief that the person’s behaviour has become less challenging, although their needs remain unmet and their wellbeing is seriously compromised.

Dangerous side effects

Antipsychotic drugs can make people, especially older people, ill. They can cause dehydration and water retention, they can increase the likelihood of chest infections or they can cause heart problems. These effects make people more vulnerable to other illnesses, for example if people become dehydrated, they are more likely to develop urine infections.

The newer antipsychotics like risperidone and olanzapine tend to cause milder and less troublesome side effects, although these drugs carry an increased risk of stroke for older people.

Studies estimate that there are at least 1,800 extra deaths each year among people with dementia as a result of them 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).

People who have dementia with Lewy bodies generally do not benefit from antipsychotics. They may cause all the effects mentioned above with no benefit. If people with dementia are experiencing hallucinations, it’s essential to consider alternative responses (see the feature on Alternatives to antipsychotic medication in this section).

Can antipsychotics be useful?

Antipsychotics can be useful to help someone manage the severe symptoms of a condition like schizophrenia, if they have this in addition to dementia. A low, short-term dose of an antipsychotic can be useful if someone’s behaviour is presenting a high risk, while other ways of meeting the person’s needs are explored and put into practice.

When a range of non-medical interventions have been tried without success, a proportion of people with dementia will experience less distress and disturbance if they take antipsychotics.

In situations where a person with dementia wants to stay at home and the person caring for them wants them to continue, the needs of both parties should be considered. Carefully monitored use of antipsychotics may enable everyone involved to have a better night’s sleep, so feel much more able to manage the demands of the day, for example.

What can care teams do to reduce the use of antipsychotics?

In summer 2011, the Dementia Action Alliance – a group of 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 benefiting 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, given that research estimates that about 30 per cent of people with dementia taking them could either stop or reduce their dose without any ill-effects (Alzheimer’s Society, 2011).

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 introduction of a new drug is considered very carefully. Most importantly, if someone’s behaviour begins to challenge others, antipsychotics should NOT be the first course of action. Rather, the person’s health care should be thoroughly reviewed and close attention given to meeting their social and psychological needs. For people already prescribed antipsychotics, it may be possible to work in partnership with the GP or psychiatrist to reduce or stop the dose, while working to make sure that the environment, care approach, activities and relationships with other people are appropriate for the person’s needs.

When a strategy for reducing the use of antipsychotics is rolled out across a service, there can be a dramatic increase in the levels of physical and emotional well-being enjoyed by people with dementia, and a corresponding increase in the satisfaction experienced by the staff (Baker, 2009).

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