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Antipsychotics, behavior and dementia: A psychiatrist’s view

January 12, 2016
by Nishendu M. Vasavada, MD
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Nishendu M. Vasavada, MD

Many individuals with Alzheimer’s or other forms of dementia and their families find the behavioral symptoms—irritability, anxiety, depression, sleep disturbances, agitation, delusions and hallucinations—to be the most challenging and distressing effects of the disease.

Antipsychotic medications, such as risperidone and haloperidol, are often prescribed to dementia patients to treat these symptoms and help them avoid higher levels of care in nursing homes and special care units.

However, with new findings from the National Institute of Mental Health on the potential harmful effects of these drugs, the impact on patients’ quality of life and the potential costs to healthcare providers, physicians should consider the importance of proper medication management combined with medical and behavioral treatments.

Use caution when prescribing antipsychotics

Today’s antipsychotic drugs are much safer and less likely to cause severe side effects than those used in the 1970s. However, studies show that when they are overused, they do put elderly patients—especially those with dementia—at a higher risk of falls, stroke and death. Other serious side effects can include sedation, shakiness, blood clots and even the worsening of dementia symptoms. Often these medications are not prescribed by psychiatrists, creating additional challenges in treating these patients.

In 2008, the U.S. Food and Drug Administration issued a warning about the use of antipsychotic drugs when treating dementia patients, finding that both first- and second-generation antipsychotics increase the risk of death among this population.

A 2012 JAMA Psychiatry study reported similar conclusions: Dementia patients taking antipsychotic drugs had increased risk of death compared to those not taking the drugs.

The evidence continues with the National Institute of Mental Health study released in October uncovering that three-quarters of seniors prescribed antipsychotics had no properly documented psychiatric diagnosis. While dementia alone is not an indication for use of antipsychotic medications, often these medications are prescribed to help address aggressive behavior and mood changes that accompany such condition. Aggressive behavior, sundowning and mood changes often lead to additional morbidity for such patients.

Medication management and behavioral treatments

Not all dementia patients are alike and they should not be treated the same. Patients should be properly evaluated to determine the type of care that would provide them with the highest quality of life. Such examination should include physical examination, laboratory studies, mental status examination and imaging studies, if necessary. In most cases, one has to balance medication management and behavioral treatments, keeping in mind the risks of treatment as well as risks of not using suitable medication. Agitation itself can lead to falls and injuries. Proper medication use along with behavior management can be crucial in preventing additional morbidity.

For dementia patients with behavioral symptoms caused by mania or psychosis, symptoms that present a danger to themselves or others, or inconsolable amounts of distress, antipsychotic drugs can help improve the patient’s quality of life. However, because of the possible dangerous side effects, patients should only receive appropriate dose for the minimum amount of time. Medication should be reviewed frequently to see if patients can take a lower dose or come off the drug gradually.

Dementia patients who do not possess these serious symptoms should receive a combination of behavioral treatments and medications on an as-needed basis. This personalized care plan encourages long-term, successful management of the physical, emotional and cognitive health challenges associated with the disease.