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It is important to remember that symptoms of stress and distress in dementia are often a temporary phenomenon or a result of external influences.
‘Watchful waiting’ and non-pharmacological interventions should be considered and possible physical causes of deterioration should be ruled out before prescribing antipsychotics.
If required for acute distress/agitation/anxiety, consider short-term use of ‘as required’ benzodiazepines prescribed at the lowest effective dose e.g. lorazepam 500micrograms (maximum 2mg over 24 hours). Clearly document the reason for use and outcome. There is no evidence base supporting the long-term regular use of benzodiazepines for symptoms of stress and distress in dementia
Do Not Initiate Antipsychotics In The Following Circumstances:
Antipsychotic medication use in older people with dementia is associated with an increased risk of stroke and death. In addition, all antipsychotics have significant adverse side effects. They should only be used as a last resort for specific symptom(s) for a specified time period, with regular monitoring of effect and any adverse effects:
When to Initiate Antipsychotic Medication:
It may be appropriate to initiate medication where:
Antipsychotic treatment may be effective for psychosis, persistent physical aggression or severe agitation. It may be appropriate to consider a short course of antipsychotic in delirium. See NHS GGC Delirium Diagnosis, Risk Reduction and Management in Acute Services for further information.1
The most important adverse effects associated with antipsychotic use in patients with dementia are Extrapyramidal Side Effects, falls, postural hypotension, dehydration, constipation, chest infections, ankle oedema, deep vein thrombosis/pulmonary embolism, cardiac arrhythmia/MI and stroke (highest risk in the first four weeks of treatment).
Patients should be kept well hydrated and as mobile as possible.
The consideration of these potential adverse effects and decisions regarding treatment choice should be clearly documented.
Medication initiation and changes to medication must be discussed with the patient if they have capacity. Where capacity is absent and there is an existing legal proxy i.e. welfare attorney or guardian, the decision to prescribe must be discussed with them, risks outlined and agreement sought. (See Appendix III for patient and carer information leaflet)
Patient information leaflets for the use of specific medications are available on the Choice and Medication. An information guide for medication used for symptoms of dementia is also available from Alzheimer’s Society.
If the patient lacks capacity and if there is no formal legal welfare proxy, the principles of the Adults with Incapacity (Scotland) Act 2000 apply and treatment options should be discussed with relevant others, such as next of kin, carer or patient advocate. In either circumstance, an appropriate Section 47 certificate of incapacity is required.
If a patient is subject to the Mental Health (Care and Treatment)(Scotland) 2003 Act, check that any psychotropic medication is included on a current T2/T3 certificate.
Antipsychotics should be commenced at the lowest possible dose, titrated carefully and reviewed within the first four weeks and after 6-12 weeks.
At review, discontinuation of the antipsychotic should be considered unless there is ongoing significant risk and/or distress.
The antipsychotic prescribing in dementia initiation and review form should be used when commencing treatment and for review throughout treatment (appendix IV of guideline)
Risperidone is licensed for the short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others.
The BNF dose in this case is 250micrograms twice daily increased according to response.
The usual dose is 500micrograms twice daily. (Maximum 1mg twice daily).3
Consider a lower starting dose of 250micrograms once daily. This can be effective and may be more appropriate for those frailer patients who are at higher risk of adverse effects.
The management of physical health care of older patients differs to that of a younger population for the following reasons:
The older adult patient should receive the same standard of physical health care as that of the younger adult, paying attention to these special features. Monitor for common side effects such as extrapyramidal side effects, antimuscarinic effects (especially constipation) and effects on blood pressure and biochemistry. Refer to Physical Healthcare Policy for further information.
Where appropriate and practical, ECGs should be completed at baseline and thereafter when clinically indicated. Abnormalities should be acted on according to significance and clinical indication. Consult with cardiologist if in doubt. See NHS GGC MU Extra Drug Induced QT Prolongation for further information on QT prolongation.2
The use of antipsychotic medication for the treatment of symptoms of stress and distress in patients with Lewy Body disease should generally be avoided as risks are greater in this patient group. In dementia with Lewy bodies and Parkinson’s disease (PD) dementia the limited evidence supports the use of cholinesterase inhibitors to target psychotic symptoms. It is acknowledged however that for more severe psychotic symptoms that have not responded to a cholinesterase inhibitor, a cautious trial with an antipsychotic may be required. First generation antipsychotics e.g. haloperidol should be avoided.
The fourth report of the Dementia with Lewy Body (DLB) Consortium4 suggests that low dose quetiapine may be relatively safer than other antipsychotics in DLB. Aripiprazole has theoretical advantages over conventional antipsychotics in DLB and is occasionally used in practice, however, the updated DLB Consortium did not recommend its use.
The use of antipsychotics in DLB is off-label. When commencing antipsychotic treatment for DLB or PD dementia, ‘start low and go slow’ e.g. 12.5mg quetiapine.
Persistent aggression in moderate to severe Alzheimer’s dementia *
250 micrograms daily to 1mg bd
DLB or PD dementia
Start at 12.5mg daily and increase cautiously as tolerated
DLB or PD dementia**
Start at 1mg aripiprazole daily and increase cautiously as tolerated eg in 1mg increments
*risperidone licensed for short term management of Alzheimer’s dementia
** anecdotal evidence for use of aripiprazole in DLB and PD dementia
*Adapted from NHS Scotland polypharmacy guidance 2018
Antipsychotics have only limited benefit in treating symptoms of stress and distress in older people with dementia and carry significant risk of harm e.g. delirium, cerebrovascular events, falls and all-cause mortality.
Medication and management of stressed and distressed behaviours:
Which patients should be prioritised for review?
Patients who have dementia and who have been on antipsychotics for more than 3 months and have stable symptoms should be reviewed by initiating team or in consultation with mental health services with a view to reducing or stopping antipsychotic medication. Priority groups for reducing antipsychotic medication include:
When should antipsychotic medication NOT be stopped?
Patients who have a co-morbid mental illness that is treated with antipsychotic medication, such as schizophrenia, persistent delusional disorder, psychotic depression or bipolar affective disorder should not have antipsychotic medication reduced without specialist advice.
How to reduce antipsychotic medication? (Also see Antipsychotic Review Flowchart)
Flowchart currently unavailable. Refer to full guidance
Last reviewed: 08 October 2019
Next review: 01 March 2022
Author(s): Dementia Strategy Group
Approved By: Mental Health Service Quality & Care Governance Group
Reviewer Name(s): Andrew Walker, Suzanne Burke