Antipsychotics, behavior and dementia: A psychiatrist’s view

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. 

  • Diet and Hydration: Elderly patients benefit from maintaining a balanced diet and staying hydrated. Because the sensation of thirst decreases with age, seniors are more at risk of dehydration, which can lead to muscle weakness, headaches and sleepiness. It’s important to manage patients’ nutrition intake and to remind them to drink before they are thirsty in order to preserve good brain function.
  • Individual & Group Therapy: Upon diagnosis, dementia patients may feel angry and scared. Emotional support from family, peers and a counselor is extremely important for their overall well-being. Whether one-on-one or in a structured group program, cognitive stimulation therapy encourages patients to focus on a variety of topics, such as current affairs, word games or word associations. These exercises provoke positive emotions and inspire communication among patients.
  • Validation Therapy: Dementia patients may show signs of confusion and say things that don’t make sense. Instead of telling patients they are wrong, physicians must talk to them with empathy. Showing compassion helps patients feel respected, valued and in control.
  • Social Stimulation: Without social interaction, individuals with dementia may become subdued and depressed. Activities as simple as going on a walk, listening to music or spending time with pets can not only enhance a patient’s quality of life, but also minimize behaviors related to psychosis.
  • Environment: Whether in an inpatient or outpatient program, patients must feel that they are in a safe place. It’s imperative to create a compassionate environment that promotes healing and security for dementia patients.

Behavioral treatments have potential to reduce costs

In 2011, the Health and Human Services inspector general’s office found that nursing home residents accounted for 20 percent of the total 8.5 million claims for antipsychotic drugs for all Medicare beneficiaries, a cost of around $309 million. As a result, CMS charged nursing homes with reducing the use of those medications by 25 percent by the end of this year.

We also know that as our population ages, we can expect the number of dementia patients to grow. Already a population more likely to be readmitted to the hospital, it can be hypothesized that with proper medication management and behavioral treatment these patients can avoid high-cost visits to an acute care setting.

Nishendu M. Vasavada, MD, is a board-certified psychiatrist at Oceans Behavioral Hospital Plano, Plano, Texas, and is a distinguished life fellow of the American Psychiatric Association. He can be reached at (972) 596-5445.



Topics: Alzheimer's/Dementia , Articles , Clinical