Scie.org.uk

DEMENTIA GATEWAY
DIFFICULT SITUATIONS
Difficult situations 9 Antipsychotic medication and dementia Key messages If the behaviours cause the person significant Research indicates that people with dementia have distress, or involve risks to the person or been prescribed antipsychotic medication too readily, and best practice guidelines now recommend a considerable reduction in their use. Antipsychotic medication can have unpleasant People living with dementia will experience and dangerous side effects for people with changes in their behaviour and mental processes dementia, making daily life much more difficult Even when a person is withdrawn, we should never treat them as if they’re not there. Why prescribe antipsychotic medication for a frighteningly, they may believe that someone or something is trying to harm them. This is known as a ‘paranoid delusion’. The changes in the brain caused by dementia affect the way a person makes sense of what’s going on around them. For Some people with dementia experience psychotic symptoms, example, a person with dementia might not recognise where although hallucinations are more likely to be something the they are living. Each person with dementia will respond and person sees rather than hears. It may be thought that behave differently in this situation. One person may find it someone is experiencing delusions when actually they have impossible to relax and will walk around, perhaps for a long misinterpreted what is going around them, for example the time, to try to get their bearings. Another person may person believes that someone has stolen their money become frightened and shout angrily because things aren’t because they don’t remember where they put it. where they expect them to be or they don’t recognise the Hallucinations and delusions are more common in some person who is trying to help them have a bath. Somebody types of dementia than others. People who have Dementia else may ask questions about where they are and when they’re going to go home over and over again in with Lewy bodies (DLB), for example, are quite likely to to understand what’s happening to them. If the person’s experience the same visual hallucinations over and over again because of the way this type of dementia affects the behaviour appears to be causing them significant distress, and particularly if there is a risk of the person harming themselves or others, sometimes a doctor will prescribe Antipsychotic medication was first prescribed to treat the psychotic symptoms that some people with dementia experience, although they quickly began to be used to treat a wider range of what are sometimes called ‘behavioural and psychological symptoms in dementia’ (and shortened to People who live with severe mental health problems, such as BPSD). These include aggression, agitation, restlessness, schizophrenia, experience what are called ‘psychotic depressed mood, anxiety as well as the more severe symptoms’. People with dementia can experience psychotic difficulties such as hallucinations or delusions. symptoms too. Hallucinations are an example of a psychotic symptom: hallucinations involve seeing, hearing, tasting, Different types of antipsychotic medication smelling or feeling something that isn’t actually there. The most common type of hallucination is hearing voices, or what Antipsychotic medication was developed to be prescribed to is called an ‘auditory hallucination’. people of working age experiencing a psychotic condition like schizophrenia. These drugs weren’t developed to be Another type of psychotic symptom is a ‘delusion’, which prescribed to older people or people whose brains are means that a person holds very unusual beliefs about themselves or those around them. A person may believe that they are God or another religious figure for example. More Older types of antipsychotics are called ‘typical’ speak clearly or understand what is being said to them, to antipsychotics or major tranquillisers. They include eat and drink or even sit or stand up comfortably. thioridazine, haloperidol and stelazine; they are not licensed People who know or care for the person may not realise that for the use of people with dementia and are rarely prescribed the drug is causing these changes and may think that the person’s dementia has worsened. Sometimes, there is relief Newer types of antipsychotics are called ‘atypical’ that the person’s behaviour has become less challenging, antipsychotics. These include risperidone and olanzapine although their needs remain unmet and their wellbeing is and, since being available from the mid-1990s, increasingly were prescribed for people with dementia. In the late 2000s, this began to change with the publication in 2009 of a major report from the Department of Health into antipsychotics for Antipsychotic medication can make people, especially older people with dementia, which questioned their heavy use. people, ill. They can cause dehydration and water retention, Further, in 2011 the Alzheimer’s Society has published best they can increase the likelihood of chest infections or cause practice guidelines pressing for a much more considered use heart problems. These effects make people more vulnerable of antipsychotic medication for people with dementia. to other illnesses, for example if people become dehydrated, Risperidone is now the only drug licensed for very cautious they are more likely to develop urine infections. use with people with dementia, and then only in situations involving ongoing aggression for up to six weeks, with the The newer antipsychotics like risperidone and olanzapine person being very closely monitored for ill-effects. tend to cause milder and less troublesome side effects, although these drugs carry an increased risk of stroke for Problems with the use of antipsychotics for people with Studies estimate that there are at least 1,800 extra deaths dementia include their unpleasant and disabling side effects. each year among people with dementia as a result of them Older people are more likely to experience these side taking antipsychotics, and that the likelihood of premature death increases if people take these drugs for months or years rather than weeks (Department of Health 2009). Antipsychotic medication can make the person feel very drowsy or cause their arms, legs and head to move without People who have Dementia with Lewy bodies generally do them meaning to, or make their body go very stiff or tremble. not benefit from antipsychotics. They may cause all the Not surprisingly, these effects can make it very hard for a effects above with no benefit. If people with dementia are person who already has difficulties as a result of their experiencing hallucinations, it’s essential to consider dementia to maintain their current abilities, for example, alternative responses (see the feature on going to the toilet or dressing themselves. Taking antipsychotic medication may make it difficult for someone to The Alzheimer’s Society (2011) published best practice guidelines to accompany the call for action. In general, it suggests that services ensure that people with dementia have their medication reviewed regularly and that any Antipsychotics can be useful to help someone manage the introduction of a new drug is considered very carefully. Most severe symptoms of a condition like schizophrenia, if they importantly, if someone’s behaviour begins to challenge have this in addition to dementia. A low, short-term dose of others, antipsychotics should NOT be the first course of an antipsychotic can be useful if someone’s behaviour is action. Rather, the person’s health care should be thoroughly presenting a high risk, while other ways of meeting the reviewed and close attention given to meeting their social person’s needs are explored and put into practice. and psychological needs. For people already prescribed When a range of non-medical interventions have been tried antipsychotics, it may be possible to work in partnership with without success, a proportion of people with dementia will the GP or psychiatrist to reduce or stop the dose, while experience less distress and disturbance if they take working to make sure that the environment, care approach, occupations and relationships with other people are In situations where a person with dementia wants to stay at home and the person caring for them wants them to When a strategy for reducing the use of antipsychotics is continue, the needs of both parties should be considered. rolled out across a service, there can be a dramatic increase Carefully monitored use of antipsychotics may enable in the levels of physical and emotional well-being enjoyed by everyone involved to have a better night’s sleep, so feel the people with dementia, and a corresponding increase in much more able to manage the demands of the day, for the satisfaction experienced by the staff (Baker 2009). What can care teams do to reduce the use of antipsychotics? In summer 2011, the Dementia Action Alliance – a group of Factsheet 408. London: Alzheimer’s Society. organisations committed to improving dementia care – put out a national ‘call for action’ asking all services providing care for people with dementia to consider whether antipsychotics are actually benefitting each individual who is taking them. The primary aim of the call to action is to reduce the number of people with dementia taking antipsychotics, Baker, C. (2009) ‘Introducing PEARL: Rewarding good given that research estimates that about 30 per cent of practice in dementia care’, Journal of Dementia Care, vol 18, people with dementia taking them could either stop or reduce their dose without any ill-effects (Alzheimer’s Society 2011). independent report by Professor Sube Banerjee. London: Social Care Institute for Excellence

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