When antipsychotic and short-term sedative medication is used

The principle

NICE NG97 1.7 places non-pharmacological approaches first for behavioural and psychological symptoms of dementia (BPSD). Antipsychotic medication is reserved for situations where:

• The behaviour is severe and persistent;
• The person, or those around them, is at risk of harm;
• Non-pharmacological approaches have been tried adequately and not worked.

The reason for caution is real: antipsychotic medication in older adults with dementia is associated with increased risk of stroke and all-cause mortality. The increase is small in absolute terms but real, and must be weighed against the potential benefit.

The licensed option

Risperidone is the only antipsychotic licensed in the UK for short-term treatment of persistent aggression in Alzheimer's Disease where non-pharmacological approaches have not worked. The standard regimen:

• Starting dose: 0.25 mg twice daily;
• Typical effective dose: 0.5 mg twice daily;
• Maximum: 1 mg twice daily, rarely used;
• Treatment duration: up to 6 weeks, with explicit review.

Treatment beyond 6 weeks is off-label and requires explicit clinical justification, ongoing monitoring, and a clear plan to taper as soon as feasible.

Other antipsychotics

• Quetiapine: used off-label, particularly where Parkinsonian features are present or where Risperidone is not tolerated. Lower extrapyramidal side effect risk.
• Olanzapine: used off-label; significant metabolic side effects.
• Aripiprazole: used off-label; less sedating but other side effects.
• Typical antipsychotics (Haloperidol, Chlorpromazine): generally avoided in dementia. Contraindicated in Dementia with Lewy Bodies and Parkinson's Disease Dementia.

Clozapine has specialist use in psychotic symptoms of Dementia with Lewy Bodies and Parkinson's Disease Dementia, with mandatory blood monitoring.

Risks

• Stroke: increased risk in older adults with dementia. The absolute increase is around 1 to 2 per cent over weeks to months of treatment;
• All-cause mortality: increased by around 1 to 2 per cent over 10 to 12 weeks of treatment;
• Falls and fractures: increased risk;
• Sedation: common; can worsen cognition;
• Extrapyramidal side effects: parkinsonism, akathisia, tardive dyskinesia;
• Metabolic effects: weight gain, diabetes, raised lipids (more with olanzapine, quetiapine);
• QT prolongation: cardiac rhythm risk;
• Severe sensitivity in Dementia with Lewy Bodies: typical antipsychotics contraindicated.

Informed consent and capacity

Antipsychotic prescribing in dementia requires explicit consideration of consent and capacity:

• Where the person has capacity, full informed consent including the increased risks;
• Where capacity is impaired, a best-interests decision under the Mental Capacity Act 2005, ideally involving family, an attorney for health and welfare, and the prescribing team;
• Documentation of the rationale, the alternatives tried, and the planned review date.

The alternatives

Before considering antipsychotic medication, the following should usually have been tried:

• Non-pharmacological approaches: PINCH-ME checklist, environmental modification, communication adjustments, music, validation;
• Optimisation of Cholinesterase Inhibitor or Memantine in Alzheimer's Disease and Dementia with Lewy Bodies;
• Treatment of co-existing depression with an SSRI (Citalopram has the strongest evidence for agitation specifically);
• Trazodone at low dose for sleep disturbance and mild agitation.

Monitoring

While on antipsychotic medication, regular monitoring should cover:

• Behavioural response (clear measurable target behaviour);
• Side effects (movement, sedation, falls, weight, metabolic);
• Cognitive function;
• Review at 6 weeks with explicit decision to continue or taper;
• If continued, ongoing review every 3 months.

Short-term sedatives

Lorazepam at low dose (0.25 to 0.5 mg) is occasionally used for acute severe agitation. Benzodiazepines should not be routinely used because they worsen confusion, falls and cognition. Z-drugs (Zopiclone, Zolpidem) carry similar concerns.

Specialist involvement

Antipsychotic prescribing in dementia should usually involve a specialist (old age psychiatry, geriatrician, neurologist or memory clinic) rather than being initiated in primary care alone. The Dementia Service can review and write to your GP with a structured plan where antipsychotic prescribing is being considered.