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Antipsychotic treatment and dementia

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Dr. Nathan Herrmann

Question: My mother’s doctor wants to treat her with an antipsychotic – should I let him?

Answer: This is an agonizing decision for many caregivers. Let’s examine some of the issues that lead to requiring the use of an antipsychotic, and then discuss what type of drugs antipsychotics are, and what are the risks and benefits of using them in older people with dementia.

Issues that may lead to antipsychotic treatment

As noted in many of my previous blogs, disturbing emotional and behavioural symptoms occur in most patients with Alzheimer’s or other types of dementia at some point in the illness. Of all these symptoms like apathy, depression, anxiety, and insomnia, often the most serious behavioral problem faced by caregivers is agitation and aggression. Approximately 20% of patients with Alzheimer’s display significant aggression and the prevalence is even higher in institutionalized patients.

Aggression occurs commonly in the context of receiving personal care (e.g. bathing, grooming, toileting) and is often directed at the caregiver. These behaviours can lead to serious physical harm since many caregivers are frail themselves. However, because many patients with dementia are physically vulnerable, these aggressive behaviors can potentially lead to the patients harming themselves. Physical aggression has been shown to increase caregiver burden, the cost of care, the risk of institutionalization, and even increase mortality.

What causes aggression in patients with dementia?

Agitation and aggression are likely caused by a multitude of factors including: environmental stressors, pain, hunger, noise, unmet physical and emotional needs, and the direct effects of the biological features of the disease process (brain pathology and chemical changes).

Treatment always begins with an appropriate medical diagnosis, ruling out any physical condition (e.g. an infection), medication effects, or environmental problems. Non-drug treatments are always tried first and can include interventions like music, aromatherapy, exercise, and multi-sensory therapies also known as “Snoezelen”.

Probably the most effective non-drug treatment is teaching the caregiver to use behavior modification techniques. However, when the most intense non-drug therapy treatments have little impact, then, drug therapies could be considered.

Antipsychotics as treatment

Of all the drug therapies used to treat agitation and aggression in Alzheimer’s disease and other dementias, by far the best studied in dozens of trials with thousands of patients, are the antipsychotics. As the name suggests, antipsychotics were originally studied to treat psychotic symptoms such as, hallucinations and delusions, in patients with schizophrenia.

In reality however, the term “antipsychotics”, is a misnomer, as many of these drugs have been shown to be useful for many other psychiatric (e.g. Bipolar Disorder, depression, etc.) and non-psychiatric conditions (e.g. nausea and vomiting).

In the studies with patients who were diagnosed with Alzheimer’s disease and other dementias, these drugs are modestly effective and can reduce agitation, aggression, along with some psychotic symptoms like hallucinations and delusions.

Possible side effects to antipsychotic drugs

Common side effects include sedation, unsteadiness (potentially leading to falls), as well as stiffness and tremor that appear like Parkinson’s disease.

Of greater concern however, and what has led to considerable controversy in the medical community, are an increased risk of stroke and death. As a result of these two potential effects, Health Canada issued warnings to physicians about the use of this class of drugs in older patients with dementia. In one study, which used data from the Food and Drug Administration (FDA) in the USA, the percentage of patients who died while taking an antipsychotic was 3.5% compared with 2.3% of the patients who were taking a placebo. Presented in another way, the risk of death was approximately 1 in 100 individuals treated with an antipsychotic over a period of about 12 weeks in these studies. So, with the risk of stroke and death, should physicians ever recommend these drugs, and should caregivers ever agree to their use?

As mentioned previously, the effects of agitation and aggression are serious and can be life-threating in themselves for patients and caregivers. Treatment with non-drug therapies are not always sufficiently beneficial. Use of antipsychotics is the best studied drug intervention for agitation and aggression in dementia and have documented modest benefits.

There are few other drug treatments that have been shown to be safe and effective. All these factors imply that the caregiver, with the help of the physician, must weigh the risks and benefits of this type of treatment. Numerous professional groups including Choosing Wisely Canada have recommended that while antipsychotics should not be treatment of first choice, when the symptoms are serious and represent a risk to the patient or others in their environment, antipsychotics can be used with appropriate monitoring and with the informed consent of the caregiver.

Get informed. Ask questions.

So as the responsible caregiver, what can you do to ensure you make a reasonable, informed choice? I suggest you ask the physician the following questions:

  • Why are you recommending the use of an antipsychotic, and what are the symptoms you hope to improve?
  • What non-drug therapies have you already tried?
  • Are there any other drug therapies besides antipsychotics that could be tried first?
  • Does the patient have any medical conditions that would make the known side-effects of antipsychotics any more likely or serious?
  • If I approve of their use, what type of dosages do you propose to use and how will you monitor their effects and their side-effects?
  • Once the patient improves, what is the plan to taper and discontinue these drugs?

Asking these questions and working with the health care team, can help you and your family make an informed decision if antipsychotics become a recommended treatment.

About the author

Dr. Nathan Herrmann

Dr. Nathan Herrmann

Dr. Nathan Herrmann holds the Lewar Chair in Geriatric Psychiatry and is Head of the Division of Geriatric Psychiatry at Sunnybrook Health Sciences Centre. For 25 years, Dr. Nathan Herrmann has been a memory disorders specialist. He has done research in the fields of mental health in the aging, including dementia, Alzheimer’s disease, depression, and suicide. Read his blog series: The Memory Doctor.