Antipsychotic drugs

Antipsychotic drugs are most commonly prescribed for behavioural and psychological symptoms, such as aggression or hallucinations, in people with dementia.

What are antipsychotic drugs?

Antipsychotic drugs (also known as ‘neuroleptics’ or ‘major tranquillisers’) are a group of medications that are usually used to treat people with mental health conditions such as schizophrenia. In some people antipsychotics can eliminate or reduce the intensity of certain symptoms. However, they also have serious side effects.

There are many antipsychotic drugs that are used to treat behavioural and psychological symptoms in people with dementia. Not all antipsychotics have the same benefits, and risperidone is the only one that is approved for this use. Risperidone is licensed for the short-term treatment of aggression in Alzheimer’s disease, if aggression poses a risk or the person has not responded to non-drug approaches.

Other antipsychotic drugs prescribed for people with dementia are done so ‘off-label’. This means that the doctor can prescribe them if they have good reason to do so, and provided they follow rules set out by the General Medical Council. The latest recommendations are that an antipsychotic other than risperidone should only be prescribed for a person with dementia if they have psychosis (delusions or hallucinations) that developed before – and so is not caused by – their dementia.

The risks and benefits of taking an antipsychotic should always be discussed with the person with dementia, where possible, and any carer.

The first prescription of an antipsychotic should only be done by a specialist doctor. This may be an old-age psychiatrist, geriatrician or GP with a special interest in dementia. The doctor should explain the alternatives, the symptoms that are being targeted, and plans to review, reduce and stop the antipsychotic.

When the prescription is reviewed, the doctor may suggest stopping the drug in one go (for people taking a low dose of antipsychotic) or a more gradual reduction (for people on a higher dose). In either case, the effect on the person’s symptoms should be closely monitored.

Who can antipsychotic drugs help?

Drug trials have shown that risperidone has a small but significant beneficial effect on aggression and, to a lesser extent, psychosis for people with Alzheimer’s disease. These effects are seen when the drug is taken for a period of 6–12 weeks.

Antipsychotic drugs may be prescribed for people with Alzheimer’s disease, vascular dementia or mixed dementia (when it is usually a combination of these two).

If a person with Lewy body dementia (dementia with Lewy bodies or Parkinson’s disease dementia) is prescribed an antipsychotic drug, it should be done with the utmost care, under constant supervision and with regular review. This is because people with Lewy body dementia, who often have visual hallucinations, are at particular risk of severe adverse (negative) reactions to antipsychotics.

Antipsychotic drugs do not help with other behavioural and psychological symptoms such as distress and anxiety during personal care, restlessness or agitation. These symptoms need other, more individualised, approaches.

For people with mild-to-moderate behavioural and psychological symptoms of any kind, the National Institute for Health and Care Excellence (NICE) recommends that antipsychotic drugs should not be prescribed in the first instance. The non-drug approaches outlined above should be used for these symptoms.

People with severe psychotic or aggressive symptoms may be offered an antipsychotic drug in the first instance, before trying non-drug approaches. Symptoms are considered severe if they are happening frequently or are causing a great deal of distress – for example, very upsetting hallucinations. Severe symptoms would also include behaviour (such as physical aggression) that poses an immediate risk of harm to the person or others around them.

For example, if a woman with dementia sometimes gets irritable and shouts at care home staff her behaviour would be best managed by understanding why she is distressed and how the staff are communicating with her. But someone who has hit other residents and staff, causing injury, may need short-term treatment with risperidone together with these non-drug approaches.

When an antipsychotic is given for severe symptoms like this before non-drug approaches have been tried, the prescription should still be reviewed after 6–12 weeks.

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Issues with the use of antipsychotic drugs in people with dementia

Antipsychotic drugs can cause serious side effects, especially when used for longer than 12 weeks. This is why all prescriptions should be monitored and if possible stopped after 12 weeks. People can stop taking the drugs after this period with no worsening of symptoms. If distressing symptoms return, they can start taking them again. People should always consult their doctor first before they stop taking any medication.

Possible side effects of antipsychotics include:

  • sedation (drowsiness)
  • parkinsonism (shaking and unsteadiness)
  • increased risk of infections
  • increased risk of falls
  • increased risk of blood clots
  • increased risk of ankle swelling
  • increased risk of stroke
  • worsening of other symptoms of dementia
  • increased risk of death.

The risks and benefits of taking an antipsychotic should always be discussed with the person with dementia, where possible, and any carer. The first prescription of an antipsychotic should only be done by a specialist doctor. This may be an old-age psychiatrist, geriatrician or GP with a special interest in dementia. The doctor should explain the alternatives, the symptoms that are being targeted, and plans to review, reduce and stop the antipsychotic.

Because of these side effects, any benefit in reducing behavioural and psychological symptoms may be at the expense of the person’s quality of life. When considering the risk of prescribing an antipsychotic, the doctor will look particularly closely at cardiovascular factors (for example, high blood pressure, irregular heartbeat, diabetes and history of stroke).

The side effects of antipsychotics were widely publicised in 2009 but there is evidence that some people with dementia who don’t need antipsychotics are still being prescribed them. For example, antipsychotics are being prescribed for people with mild symptoms before non-drug approaches have been tried. Other people may be kept on an antipsychotic for too long without a review at 12 weeks or a plan for them to come off the drug. There is an ongoing national drive to reduce the inappropriate prescribing of antipsychotic drugs. Alzheimer’s Society would like to see these drugs used only when they are really needed.

Tips for carers: questions to ask the doctor about antipsychotics

Where possible, both the person with dementia and their carer should be closely involved in decisions about the person’s treatment and should be shown their care plan. The following questions may help with discussions:

  • Why is the person being prescribed an antipsychotic? Which symptoms is the drug meant to be helping with?
  • Have possible medical causes of their symptoms (such as infection, pain or constipation) been ruled out?
  • Can non-drug approaches be tried first?
  • What can I do as a carer to help? Do you need to know more about the person as an individual to work out what may be causing their symptoms?
  • How will we know if the drug is working?
  • What side effects might the drug cause?
  • What is the plan for the person to come off the antipsychotic?
  • When will the use of this drug be reviewed?

Further reading