Dementia: Antipsychotic drugs may be overprescribed to treat symptoms

• Few medications are available to treat agitation and other psychological and behavioral symptoms of dementia.
• Antipsychotic medicine can cause stroke or sudden cardiac death.
• Researchers say people with dementia are likely prescribed antipsychotic drugs too often and inappropriately.

Antipsychotic medications are likely overprescribed and misused in people with Alzheimer’s disease and related dementias who receive home health care.

That’s according to a new study published in the Journal of the American Geriatrics Society, which concludes that this use can lead to worse patient outcomes.

Researchers looked at information on 6,684 adults 65 years and older who received care from a home healthcare agency in New York in 2019.

They reported that people with Alzheimer’s disease or related dementia were more than twice as likely to use antipsychotics than those without – 17% versus about 6%.

Antipsychotic medications and dementia

Only a few antipsychotic medications have been authorized to treat dementia-related symptoms.

However, some physicians use the drugs off-label to treat symptoms such as agitation, aggression, and psychosis, which are sometimes behavioral and psychological symptoms of dementia.

“Antipsychotics are not considered a first-line treatment for people with dementia with behavioral problems,” said Dr. David Merrill, a geriatric psychiatrist and director of the Pacific Neuroscience Institute’s Pacific Brain Health Center in California who was not involved in the study.

“Often, they are rightly prescribed in the hospital after an injury or illness for delirium and confusion, and then they are continued at home. The patient may need support at home, but not more medication,” he added.

“When antipsychotics are prescribed, the doctor should be vigilant on management,” Merrill noted. “For example, taking them off the medications every couple of months to see if they are still needed.”

The study authors reported that older adults with Alzheimer’s or related dementia who experience the following are more likely to be prescribed antipsychotic medication:

• Limitations in activities of daily living
• Taking more medications
• Having behavioral or psychological symptoms
• Living alone

Antipsychotic medication can have serious adverse effects, such as stroke and sudden cardiac death, when given to older adults with dementia.

“Movement is also a concern,” Merrill said. “Antipsychotics tend to slow a person down and cause rigidness and unsteadiness, increasing the risk of falling.”

The most prescribed antipsychotic reported in the study was quetiapine, a drug approved to help manage symptoms of schizophrenia, bipolar disorder, and major depressive disorder.

New dementia drug raises some concerns

In May 2023, the Food and Drug Administration (FDA) approved brexpiprazole (Rexulti) for treating agitation in people with dementia.

The Alzheimer’s Association supports using this medication. However, there are some contradictory results in studies.

A recent report in the BMJ indicated that the first two placebo-controlled trials produced unconvincing results. A third trial did show a reduction in symptoms. However, these were not considered clinically significant.

Due to the lack of choices doctors have when treating agitation in people with dementia, some find Rexulti acceptable.

Drug reactions can differ from person to person. Physical and mental history, as well as current symptoms, should be considered when deciding which treatments to use.

Agitation in people with dementia

Agitation can show up in many ways in people with dementia.

Some become restless and fidget. Others consistently tap their feet. Some may try to leave the house.

Agitation can be a sign of changes in the brain or distractions and noise in the environment. It can be a sign of frustration because people can’t do things that they once did.

It can also be a side effect of some medications, according to the Alzheimer’s Society. This can sometimes be alleviated by lowering the dose or changing to a different medication. You can check the side effects of each medication and speak with your primary physician if there are some that cause restlessness or agitation.

As the disease progresses, some people become aggressive.

According to the National Institute on Aging, aggression is when a person lashes out verbally or tries to hit or hurt someone. Cambridge University in the United Kingdom describes agitation as excessive motor or verbal activity without focus or intent. Aggression is a provoked or unprovoked behavior intended to cause harm.

Aggressive behavior often start in the mid stage of dementia, when the person is losing their ability to carry out daily activities and must rely on other people.

Aggression and agitation are common in Alzheimer’s disease and other forms of dementia, according to Harvard Health.

Calming techniques for people with dementia

There are some non-medication ways of helping someone with dementia, according to the Alzheimer’s Association,

These include:

• Offer guided choices between two options
• Focus on pleasant events
• Ask permission for what you are doing
• Use calm, positive statements
• Listen to frustrations
• Provide reassurance
• Involve the person in an activity such as listening to music or an activity they enjoy to divert their attention away from their anxiety
• Modify the environment to decrease noise and distraction
• Distract the person by taking a walk or going for a car ride

You might also want to check the side effects of other medications to see if their side effects are contributing to the agitation.

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