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APA releases guidelines on antipsychotic use in dementia

The American Psychiatric Association recently published new recommendations for the use of antipsychotics for agitation or psychosis in individuals with dementia.

“Expert consensus suggests that use of an antipsychotic medication in individuals with dementia can be appropriate, particularly in individuals with dangerous agitation or psychosis, and can minimize the risk of violence, reduce patient distress, improve patient’s quality of life, and reduce caregiver burden,” Victor I. Reus, MD, of the APA Practice Guideline Writing Group and the University of California, San Francisco, and colleagues wrote. “However, in clinical trials, the benefits of antipsychotic medications are at best small whether assessed through placebo-controlled trials, head-to-head comparison trials, or discontinuation trials. There is also consistent evidence that antipsychotics are associated with clinically significant adverse effects, including mortality.”

New recommendations include:

• Nonemergency antipsychotic treatment should only be used when agitation and psychosis symptoms are severe, dangerous and/or cause significant distress in patients with dementia;
• Patient response to nonpharmacological interventions should be reviewed before prescribing antipsychotics;
• Before prescribing antipsychotics, physicians should assess benefits and risks and discuss them with patients and patient caregivers;
• Treatment should begin at a low dose and increase, if necessary, to the minimum effective dose;
• If a patient experiences significant adverse effects, risks and benefits should be reviewed to determine if discontinuation is needed;


Renée Binder


• Antipsychotic treatment should be tapered and withdrawn if there is no significant response after 4 weeks;
• Within 4 months of initiation, physicians should attempt to taper and withdraw antipsychotics among patients with adequate treatment response;
• Among patients who are tapering, symptoms should be assessed at least once a month during tapering and at least 4 months after treatment discontinuation;
• Long-acting injectable antipsychotics should not be used unless it is for a co-occurring chronic psychotic disorder; and
• If nonemergency antipsychotic treatment is needed, haloperidol should not be used first.

The guidelines also emphasize that any medication given to individuals with dementia should be one part of a patient-centered comprehensive treatment plan that includes appropriate pharmacological and nonpharmacological treatments.

“While the use of antipsychotics is appropriate for some patients with dementia, it can be difficult to identify the individuals and the specific circumstances. A decision should be made only after thorough assessment and review of potential benefits and harms of antipsychotic treatment as well as other possible treatment options,” Renée Binder, MD, president of the APA, said in a press release. – by Amanda Oldt

Disclosure: The researchers report no relevant financial disclosures.