Antipsychotics and other drug approaches in dementia care

Antipsychotic drugs may be prescribed for people with dementia who develop changes such as aggression and psychosis. However this is usually only after other drugs have been tried such as anti-depressant, anti-dementia and anticonvulsant drugs.

Drugs for behavioural and psychological symptoms
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Antidepressant, anti-dementia and anticonvulsant drugs

Antipsychotic drugs may be prescribed for people with dementia who develop changes such as aggression and psychosis, but usually only after other drugs have been tried.

Certain antidepressants, anti-dementia drugs and anticonvulsants may be helpful in treating these changes. There is less evidence about whether some of these drugs work than there is for antipsychotics, but they generally have less severe side effects.

Antidepressants

Antidepressants such as sertraline, citalopram, mirtazapine and trazodone are widely prescribed for people with dementia who develop changes in mood and behaviour.

There is some evidence that they may help to reduce agitation – particularly citalopram. However, the dose of citalopram needed to reduce agitation may cause severe side effects, including a higher risk of falls and a dangerously irregular heartbeat. For this reason, citalopram is not licensed for treating agitation.

However, some doctors may prescribe citalopram in lower doses if they think that the person’s agitation may partly be caused by anxiety or depression.

Anti-dementia drugs

The main type of drugs used to treat problems with memory and thinking are acetylcholinesterase (AChE) inhibitors.

AChE inhibitors include donepezil, rivastigmine and galantamine. They are routinely offered to people with Alzheimer’s disease, dementia with Lewy bodies, Parkinson’s disease dementia, or any mixed dementia that includes one of these types (for example, Alzheimer’s disease with vascular dementia). They are normally prescribed soon after diagnosis and continued throughout the course of the person’s dementia.

There is some evidence that these drugs may also slightly reduce agitation in people with moderate-to-severe Alzheimer’s disease. They may also help to reduce hallucinations and delusions in people with Lewy body dementia. However, they are rarely prescribed specifically for these purposes because most people with these types of dementia will already be taking them anyway.

Another drug used to treat problems with memory and thinking is memantine. This tends to be used in addition to an AChE inhibitor as dementia progresses.

Memantine is sometimes prescribed to reduce levels of aggression or psychosis and has fewer risks and side effects than antipsychotic drugs. It should not be prescribed if the person has vascular dementia.

To find out more read our information on drug treatments for Alzheimer’s disease.

Anticonvulsants

Anticonvulsants are used to prevent fits in people with epilepsy. They are occasionally used for aggression and agitation in people with dementia. However, there is little evidence that they are effective, and they have a wide range of side effects, so they are not recommended for this purpose.

Antipsychotic drugs

What are antipsychotic drugs?

Antipsychotic drugs are used to treat people who are experiencing severe agitation, aggression or distress from psychotic symptoms, such as hallucinations and delusions. They tend to be used only as a last resort, such as when the person, or those around them, are at immediate risk of harm.

For some people, antipsychotics can help to reduce the frequency or intensity of these changes. However, they also have serious risks and side effects, which the doctor must consider when deciding whether to prescribe them.

The first prescription of an antipsychotic should only be done by a specialist doctor. This is usually an old-age psychiatrist, geriatrician or GP with a special interest in dementia.

What antipsychotic drugs may be prescribed for a person with dementia?

There are several antipsychotic drugs that may be used. Each one has slightly different effects on the brain and has its own potential risks and side effects.

The drug with the most evidence to support its use in dementia is risperidone. It is licensed for short-term (up to six weeks) treatment of persistent aggression in people with moderate-to-severe Alzheimer’s disease when there is risk of harm to the person or others. However, this is only if non-drug approaches have already been tried without success.

An older antipsychotic called haloperidol is licensed for use in people with Alzheimer’s disease or vascular dementia. However, most doctors consider its risks and side effects in people with dementia to be too severe. It tends to be used only in emergencies as a last resort.

What are off-label antipsychotics drugs?

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 guidance set out by the General Medical Council.

A doctor may choose to prescribe an off-label antipsychotic drug when it offers a better balance of benefits and risks for an individual patient. For example, risperidone may be effective in people with dementia, but it also increases the risk of having a stroke. So if a person has already had a stroke it might be safer to prescribe an off-label drug that doesn’t carry this risk, even though it might be less effective.

The off-label antipsychotics most often used for patients with dementia are:

  • quetiapine and clozapine – These drugs are mostly used if a person has dementia with Lewy bodies or Parkinson’s disease dementia. This is because they interfere less with drugs that treat other symptoms of these conditions. However, there is very little evidence that they are effective. They may also cause the person to become drowsy or dizzy, which can increase the risk of falling
  • olanzapine – This is not as effective as risperidone, but may be prescribed if the doctor needs to sedate the person to stop them becoming agitated. However, it can make confusion worse, affect the person’s metabolism and increase the risk of them having a stroke
  • aripiprazole – This is one of the newest antipsychotic drugs. Although it works well for people with schizophrenia, there is much less evidence that it reduces hallucinations and delusions in people with dementia, so it is not often used.

How are antipsychotic drugs reviewed?

Antipsychotic drug treatments should be reviewed after six or 12 weeks, or both.

When the prescription of an antipsychotic 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) known as ‘tapering’. In either case, the effects on the person’s behavioural and psychological changes should be closely monitored. If they seem to be getting worse, it may be necessary to restart or increase the dose again.

If the person had a pre-existing mental health condition before they developed dementia and this was managed with antipsychotic drugs, they should continue to take them as prescribed by their psychiatrist.

Who can antipsychotic drugs help?

Some antipsychotics can have a small but significant beneficial effect on agitation, aggression and, to a lesser extent, psychosis in people with Alzheimer’s disease. Improvements are normally only seen once these drugs have been taken for several weeks.

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

If a person with 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 these types of dementia, who often have visual hallucinations, are at particular risk of severe negative reactions to most antipsychotics.

The doctor is likely to choose a drug with the least side effects, but they will only be able to use very small doses. This is unlikely to have much effect on agitation and psychosis.

What symptoms do antipsychotics not help with?

Antipsychotic drugs do not help with other behaviours such as:

  • distress and anxiety during personal care
  • repetitive vocalisations
  • walking about
  • social withdrawal
  • changes in levels of inhibitions (for example, doing or saying things that may be inappropriate).

These changes are likely to need personalised non-drug approaches.

Our dementia advisers are here for you.

Issues with the use of antipsychotic drugs

Antipsychotic drugs can cause serious side effects, and the risk increases with continued use over weeks and months.

Possible negative effects of antipsychotics include:

  • drowsiness or confusion
  • shaking, unsteadiness and reduced mobility
  • worse than usual dementia symptoms, such as problems with thinking and memory
  • higher risk of swelling around the lower limbs
  • higher risk of infections (particularly of the chest and urinary tract)
  • higher risk of falls and fractures
  • higher risk of blood clots
  • higher risk of having a stroke
  • higher risk of dying earlier than if they hadn’t taken the drugs.

The decision to use antipsychotics should be taken very seriously. Benefits may sometimes come at the expense of the person’s health and quality of life.

When considering prescribing an antipsychotic, the doctor will check if the person has high blood pressure, an irregular heartbeat, diabetes or a history of strokes. This is because these conditions carry additional risks for a person taking antipsychotic drugs.

There is evidence that some people with dementia who may not need antipsychotics are still being prescribed them. For example, they are being prescribed to treat distress or aggression before non-drug approaches have been tried thoroughly. Also, some people are kept on an antipsychotic for too long without a review at 12 weeks or a clear plan for when they should come off the drug.

There is an ongoing national drive to reduce inappropriate prescribing of antipsychotic drugs in dementia, especially for people in the later stages of dementia living in residential care. Alzheimer’s Society would like to see these drugs used only when they are really needed.

Questions to ask the doctor about antipsychotic drugs

If the person with dementia can consent to taking an antipsychotic drug, they need to be properly informed about the drug.

If a doctor is making the decision, the person with dementia and their carer should still be involved as much as possible and should be shown their care plan.

The following questions may help with discussions:

  • Why is the person being prescribed an antipsychotic? Which specific behaviours or psychological changes is the drug meant to be helping with?
  • Have possible medical causes of the changes (such as infection, pain or constipation) been investigated and ruled out?
  • Are there any non-drug approaches that haven’t been tried which might help?
  • What can I do as a carer to support the person?
  • Is there anything else you need to know about the person (such as their personality, life history or other health problems) to work out what may be causing the changes?
  • How will we know if the drug is working?
  • What are the risks associated with taking this drug?
  • What side effects might the drug cause and how can they be managed effectively?
  • What is the plan for the person to come off the antipsychotic?
  • When will the continued use of this drug be reviewed?

Useful organisations

General Medical Council (GMC)

Telephone
0161 923 6602 (9am–5pm Monday–Friday)

Email
[email protected]

Website
www.gmc-uk.org

The GMC helps protect patients and improve UK medical education and practice by supporting students, doctors, educators and healthcare providers. It provides guidance on the prescribing of medication, including off-label drugs.

Medicines and Healthcare products Regulatory Agency (MHRA)

Telephone
020 3080 6000

Email
[email protected]

Website
products.mhra.gov.uk

The MHRA products website provides detailed information on specific drugs, and the ‘Yellow Card’ scheme for reporting side effects.

Review details

Last reviewed: July 2021
Next review due: July 2024

Reviewed by: Dr Sharmi Bhattacharyya, Consultant & Clinical Lead, Older People’s Mental Health, North Wales Betsi Cadwaladr University Health Board and Dr Manoj Rajagopal, Consultant Old Age Psychiatrist and Associate Medical Director, Lancashire & South Cumbria NHS Foundation Trust

This information has also been reviewed by people affected by dementia.

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