Alternatives to antipsychotic medication

The case against antipsychotics

It is now known that too many people with dementia have been prescribed antipsychotic medication for too long periods of time (Department of Health, 2009). Research estimates that antipsychotic drugs are inappropriate for about two-thirds of the people with dementia who take them, though do provide benefit for a small minority (see Department of Health, 2009).

Antipsychotics are often accompanied by unpleasant and dangerous side effects, and studies have estimated that there are at least 1,800 extra deaths each year among people with dementia as a result of taking antipsychotics (Department of Health, 2009) (for more on this, see the feature Antipsychotic medication and dementia in this section).

A proper assessment and a thorough understanding of the role of the array of interventions available for people with dementia is essential so the correct and safest treatment can be delivered.
Professor Alistair Burns in Optimising treatment and care for people with behavioural and psychological symptoms of dementia (Alzheimer’s Society, 2011)

It is also now recognised that using antipsychotic medication as an early response to types of behaviour that challenge others often creates additional problems for the person and effectively silences the message that the person is attempting to communicate through their behaviour.

For example, a person with dementia is prescribed antipsychotics because they have started to walk up and down, refuse to eat and are reluctant to let anyone help them with personal care. This use of medication ignores the person’s messages that they are lonely and looking for company, or that they believe that they have to pay for their food and have no money or that they have pulled a muscle in their back and it’s very painful to sit still or move in certain positions. There may be occasions when a person who is very restless, not eating and refusing help with personal care may benefit from taking antipsychotics, but other non-medical approaches should always be tried first as they are very likely to beneficial.

Why have antipsychotic drugs been overprescribed?

People in the UK and the rest of the developed world are living longer than ever before. This has led to a very rapid increase in the number of people with dementia – currently about 750,000 people in the UK. Services to support people with dementia haven’t developed at the same pace. Many GPs aren’t as knowledgeable as they feel they should be, for example, so people may not be diagnosed and offered help promptly. Many people find that there is limited support available once they or a family member have been diagnosed, especially when the dementia is quite mild (Department of Health, 2009).

Approximately one-third of people with dementia live in a care home and it is this group who are most likely to be prescribed antipsychotics. This is partly because people living in care homes tend to have more advanced dementia and have often been assessed as being at some sort of risk while living in the community. Many care homes haven’t adapted to the fact that the proportion of residents with dementia (as opposed to simply being physically frail) has increased significantly over the past 10 to 15 years. So it may be that a person’s behaviour is described as ‘challenging’ because staff lack the necessary training, skills or expertise to understand what the person is trying to communicate. Out-of-date attitudes about dementia, such as ‘There’s nothing that can be done’ or ‘It’s just the dementia’ can prevent creative interventions being developed.

It may be that the service lacks the necessary resources and specialist input to truly meet the person’s needs. In these instances, antipsychotics are sometimes prescribed in the absence of alternative responses. Community support services for people taking antipsychotics and those administering them are patchy and often inadequate, meaning that regular reviews may not occur and that the person’s underlying needs never get fully explored (Department of Health 2009).

The benefits of stopping antipsychotics

Although a small minority of people with dementia taking antipsychotics won’t benefit from stopping the medication or a reduced dosage, the majority will. People generally get relief from the side effects of trembling, loss of motor control, tiredness and water retention, among others, and feel better in themselves. People’s abilities often improve and they find that they are able to function much better on a daily basis. It may even seem that the dementia has improved. Sometimes carers and family are amazed by the change in a person’s appearance, energy levels and capacity to engage when they have stopped taking antipsychotics or reduced the dosage.

A preventative approach: good physical health care

When someone with dementia is behaving in ways that challenge others, their basic health care can get overlooked. Any physical health problems the person has must be identified and treated promptly. Untreated infections can cause increased confusion and hallucinations. Constipation, dehydration and inadequate food can also make someone’s dementia-related difficulties seem worse.

Poor hearing or eye sight is disabling and frustrating for the person. Hearing or sight problems should be quickly addressed and appropriate aids provided.

Untreated pain is a significant factor in aggressive, agitated or restless behaviour, and it’s essential that pain is identified and responded to promptly.

A preventative approach: knowing the person

As well as knowing about the different types of dementia and the difficulties thast these produce, it’s important that care staff closely observe individuals with dementia, recognise ‘trigger’ situations and be familiar with each person’s early signs of stress and distress. For example, if it known that someone often starts pacing around and calling out to go home around tea-time, staff can plan to try to engage the person in an activity they find relaxing like listening to music, to take time to let the person talk about what is bothering them or just sit close by them in a quiet place.

If someone is aggressive because they are frightened and angry, staff may be able to identify triggers and take action to reduce them. For example, someone may become angry if they feel they are being prevented from going home. Staff may be able to make the person’s care environment more homely, and meet the person’s needs for comfort and security through developing a closer relationship with them and taking time to listen to them express their thoughts and feelings about what has happened to them.

A preventative approach: attention to the environment

It’s important that the environment is adapted to promote the comfort, freedom of movement and independence of a person with dementia as much as possible. Good use of signs can prevent people from becoming angry that they can’t find the toilet, for example, and controlled noise can promote a calm atmosphere. These types of care practices compensate for the difficulties that people are experiencing (see the Dementia-friendly environments section’).

Person-centred care and personalised solutions

The goal of person-centred care is to identify and find ways of meeting the unique needs of each individual with dementia, always trying to increase the amount of time that a person spends in a state of wellbeing. People with dementia have individual likes, dislikes, interests, abilities, difficulties, hopes and fears just like everyone else and this information should be used as the basis of care provision.

A person with dementia will do their best to let others know how they are faring and what they need through their behaviour, as other communication channels begin to fail. Using antipsychotic drugs as an early response to behaviour that challenges others often creates additional problems for the person and effectively silences their message (see the feature on Antipsychotic medication and dementia).

Very often when someone is having difficulties, small changes in their daily life experience can greatly lessen their distress and increase their wellbeing. Care staff can increase the one-to-one time they spend with a person in conversation, reading something out loud that the person might enjoy or just sitting in close contact. A person may get some relief from loneliness or troubling feelings by going out for a walk in company, having a hand massage or having someone take the time to respond to needs as they arise, like having an extra blanket because they feel a bit chilly. Interventions that focus on stimulating the senses rather than requiring someone with dementia to interact with another person may be effective if someone is withdrawn (Kitwood, 1997).