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Dementia - antipsychotic medications to care for people with behavioural and psychological symptoms

Position statement Last updated: May 2023 Published in Australia Reference: PS #112

Best practices when considering the use of antipsychotic medications to care for people with behavioural and psychological symptoms of dementia (BPSD).

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this Position Statement to inform psychiatrists and the broader community about the utility of antipsychotic medications to care for people with BPSD.

Key messages

  • People with dementia who experience BPSD should be primarily supported and treated with non-pharmacological strategies, informed by a culturally appropriate, person-centred, multidisciplinary assessment.
  • While there are appropriate indications for the use of antipsychotic drugs in dementia, people with dementia are often prescribed antipsychotics inappropriately.
  • Antipsychotic drugs are to only be prescribed to people with BPSD when specific symptoms are severe, disabling, or where a risk of significant harm exists.
  • The clinical decision regarding which antipsychotic medication to prescribe should be made by a doctor with appropriate training and expertise (typically a psychiatrist, psychogeriatrician, or geriatrician) and based on a careful risk–benefit analysis for each patient.
  • Before making any clinical decision, psychiatrists should endeavour to obtain informed consent from patients and/or their carers, explaining the potential risks and benefits of various treatment options to care for people with BPSD.
  • To address people with BPSD’s clinical, functional, cognitive, and emotional needs, thus limiting the need for antipsychotics, a suitably resourced and trained wider healthcare workforce is imperative.

Evidence

More than 55 million people live with dementia worldwide, with nearly 10 million new cases every year.[1] Among people aged 65 years and over, dementia was the second leading cause of total burden of disease and injury (accounting for 7.7% of disability adjusted life years).[2] BPSD affects about 97% of community-dwelling patients with dementia and has a significant impact on prognosis, institutionalisation, and carer well-being.[3]

BPSD refers to the spectrum of non-cognitive and non-neurological symptoms of dementia. These symptoms include agitation, aggression, psychosis, depression and apathy, emotional, perceptual, and behavioural disturbances, restlessness, pacing and wandering, anxiety, elation, irritability, disinhibition, delusions and hallucinations.[3-7]

Background

The increasing prevalence and costs of dementia and BPSD underlines the importance of providing high quality care to those affected. BPSD are associated with cognitive and functional decline, increased hospital length of stay, hospital complications, earlier nursing home placement, and increased rates of psychiatric and cardiovascular disorders in family, whānau and/or carers.[8,9]

Despite the necessity of effective care for BPSD, there is concern that antipsychotics are over and inappropriately prescribed to control behaviours in people with dementia that family, whānau and/or carers may find challenging.[10]

Antipsychotic drugs can reduce the severity of delusions, hallucinations, aggression and agitation but are minimally effective for other BPSD symptoms such as disinhibition, wandering and inappropriate voiding. These drugs are also linked to serious side effects, have a mild to moderate benefit, and do not address many of the underlying causes of BPSD such as unmet psychosocial needs.[11]

Regulatory changes across Australia and New Zealand attests to these risks. Within Australia, amendments to the Aged Care Act 1997 (July 2021), which regulate restrictive practice arrangements, aimed to improve safeguards for care recipients by placing an increased responsibility on residential aged care providers. Recommendation 65 of the Royal Commission into Aged Care Safety and Quality also recommends reform to restrict prescription of antipsychotics in residential aged care to only a psychiatrist or a geriatrician.[12]

The role of psychiatrists

Considerations before prescribing antipsychotic medications

While dementia clearly has a biological substrate, the common psychiatric complications of dementia require the involvement of psychiatrists as experts in care and support.[13] Psychiatrists have a key role in providing differential assessment, diagnosis and care for older people with mild to severe mental illness, including people for whom dementia is complicated by severe behavioural and psychological symptoms.

It is imperative that a comprehensive and holistic assessment of the person with dementia is undertaken when considering the use of anti-psychotic medications. An assessment of health history (including premorbid primary psychosis and an existing requirement of antipsychotics), behaviour, personality, mental state and risk identifies priorities regarding the nature and urgency of interventions, whether they be environmental modifications or the commencement of antipsychotic medications.[14] There should be an established, clear baseline regarding the frequency and severity of target behaviours.[14]

Antipsychotics should not be prescribed without the development and implementation of an individual and systematic care plan to tailor interventions to the patient’s preferences and capabilities. Person-centred care when managing BPSD involves (where possible) choosing an appropriate setting, treating discomfort (e.g., pain, constipation, urinary retention, environments that are too warm/cold/loud), and implementing non-pharmacological interventions.[14] There should also be a focus on the specific care needs of certain populations such as people from culturally and linguistically diverse (CALD) communities, Aboriginal and Torres Strait Islander peoples, and people from low socioeconomic backgrounds.

The expertise of carers and/or the family/whānau of the person with dementia is critical before a decision is made to commence antipsychotic medication. Carers should be prompted to describe what they are seeing alongside other essential elements of history such as the onset (i.e., acute, sub-acute, or chronic/progressive), frequency, timing, and trajectory of the disturbances, alongside any relationship to environmental or medication changes.[14]

To avoid the inappropriate prescription of antipsychotics to treat BPSD, the effective management of BPSD is required prior to a decision to prescribe. This is best achieved through a coordinated interprofessional health care team that partners with the patient's home carer.[9] Collaboration and communication among the interprofessional team is key to improving outcomes for patients.

Before making any clinical decision, psychiatrists should endeavour to ensure patients and/or their carers are informed about treatment. It is necessary that information about the risks and benefits of prescribing a medication to a person with dementia is conveyed to the person or their substitute decision maker, and that this is understood.

In acute situations, when the safety of the patient or significant others are at risk, the common law principle of necessity allows a doctor to act in an emergency in the best interests of a patient unable to provide valid consent to their own treatment. In such circumstances treatment should be initiated quickly, with doses reviewed regularly and targeted appropriately to minimise distress and injury. The patient should also be closely monitored for any response or adverse effects and consent obtained from appropriate decision-maker as soon as is practicable.

Considerations when prescribing antipsychotic medications

If nonpharmacological approaches are insufficient or fail, and the patient has applicable symptoms or is at risk to harm themselves or others, consider antipsychotic medications to treat BPSD. The choice of antipsychotic to use must be a clinical one based on a careful risk–benefit analysis for each patient.[16] Psychiatrists should consider:

  • Using a “start low, go slow” strategy, a systematic, sequential trialling of one drug at a time, with side effects being monitored regularly and with the drug being ceased immediately if significant adverse effects are noted. Medications should be given an adequate trial before concluding if they are effective after one-two weeks.[16,17]
  • Establishing a clear baseline for assessing the effects of treatment. For overall BPSD, clinicians can use a standardised instrument to rate and monitor symptoms, such as the Neuropsychiatric Inventory (NPI) or the Behavioural Pathology in Alzheimer’s Disease rating scale (BEHAVE-AD).[18] The Cohen-Mansfield Agitation Inventory (CMAI) specifically evaluates agitated behaviours only, dividing them into four categories (physical, verbal, aggressive, or non-aggressive).[18]
  • Trialling alternative medications in the management BPSD (SSRIs, Cholinesterase Inhibitors or Memantine), with the use relevant medication algorithms where appropriate.[11,19-21]
  • Using systems to monitor and review prescriptions whenever antipsychotics are prescribed. The use of antipsychotics should be time limited and reviewed for potential discontinuation as the natural history of BPSD is variable.
  • Adhering to protocols (e.g., General Medical Council [GMC] and National Institute for Health and Care Excellence [NICE] – Social Care Institute for Excellence [SCIE] protocols).
  • Obtaining a thorough patient history. For example, a recent electrocardiogram should be obtained before commencement of antipsychotics for the presence of cardiovascular disease and vascular risk factors, or a thorough neurological evaluation (especially in patients with frontotemporal dementia, who frequently present with behavioural disturbances rather than memory impairment).[22]
  • Trialling antipsychotic tapering every 3 to 6 months (sooner if adverse effects emerge). If an antipsychotic is insufficiently beneficial, an alternative antipsychotic can be tried once the ineffective agent is ceased.
  • Re-evaluating environmental factors at each step to determine if non-pharmacological interventions are necessary.[6]
  • Obtaining informed consent with the patient and/or their carer before starting a patient on antipsychotic medication. Within Australia, psychiatrists should note that requirements for informed consent pertaining to chemical restraint vary across states and territories.

Models of Care

Co-produced care involving people with lived experience of people with BPSD, their family/ whānau and/or carers should feature strongly in system change. Lived experience within a multidisciplinary care team supports clinical decision making, and the risk-benefit analysis required for a decision on antipsychotic use. Similarly, clinical expertise assists carers by improving their understanding of BPSD and the efficacy of antipsychotics. Education programs on caring for people with BPSD, including developmentally appropriate information for young carers, should be a priority to support this care model.[23] Programs should also be available for health practitioners on how to include carers in the ongoing care of BPSD, with or without antipsychotics.[24]

Systemic Change

There is a pressing need for systemic change to support best practice when caring for people with BPSD. This requires leadership and continuing investment in the delivery of appropriate that includes policies on workforce and training to support practice change.[25]

Systemic change should ensure all health services have appropriate policies, resources and frameworks aimed at minimising, and working towards the use of antipsychotics as a last resort. There must be a clear, overarching model of care, which balances supporting the autonomy of people with BPSD and ensuring the safety of the individual, staff and the community. Such change must entail a consistency of definitions and data across jurisdictions to allow for more accurate data collection on the use of antipsychotics in Australia and New Zealand, and clear professional links between old age psychiatry and geriatric medical services.[26]

Due to psychiatrists’ central role in the prescription of an antipsychotic, the recruitment and retention of the psychiatry and old age psychiatry workforce is crucial. Where there are barriers to recruitment, training and retention in at undergraduate, postgraduate and mid-career levels, resources should be allocated on the basis of need. This should be supported by the individual psychiatrist and/or service provider, to ensure that trainee psychiatrists, psycho-geriatricians, geriatricians or alike have the appropriate skills to undertake risk–benefit analysis for each patient.

To address people with BPSD’s clinical, functional, cognitive, and emotional needs, thus limiting the need for antipsychotics, a suitably resourced and trained wider healthcare workforce is imperative. This maximises positive clinical outcomes and quality of life by supporting the psychiatrists’ assessment of the patient’s symptomology, environment, and their subsequent need for an antipsychotic. Ongoing professional development across health care settings, with an understanding of someone with dementia’s needs at its heart, is required.[12] Upgrading the skills, knowledge and capabilities of this workforce, alongside sufficient resourcing, will provide carers with the skills and capacity to effectively care for someone with BPSD.

Recommendations

  • To primarily treat people with dementia who experience BPSD with non-pharmacological strategies, informed by a culturally appropriate, person-centred, multidisciplinary assessment.
  • To only prescribe antipsychotics for people with dementia for symptoms such as delusions, hallucinations, aggression or agitation that are severe, disabling or where a risk of significant harm exists.
  • To have a psychiatrist, psychogeriatrician or geriatrician with appropriate training and expertise decide the appropriate antipsychotic, using a careful risk–benefit analysis for each patient.
  • To incorporate the lived experience and consent of the patient and/or their carer and relevant decision maker whenever a clinical decision is made to care for someone with BPSD.
  • To develop both the psychiatric and wider healthcare workforce, to support their competency when caring for and assessing someone with BPSD before deciding the appropriateness of antipsychotic prescription.

Additional resources

References

  1. World Health Organisation. ‘Dementia Factsheet’. 2021.
  2. Australian Institute of Health and Welfare. Dementia in Australia. 2022.
  3. Cloak N, Al Khalili Y. Behavioral And Psychological Symptoms In Dementia. In: Treasure Island (FL): StatPearls Publishing. 2022 Jan
  4. NSW Ministry of Health and Royal Australian and New Zealand College of Psychiatrists. Assessment and management of people with behavioural and psychological symptoms of dementia (BPSD). 2013.
  5. Guideline Adaption Committee. Clinical practice guidelines and principles of care for people with dementia. 2016.
  6. Cerejeira J, Lagarto L, Mukaetova-Ladinska E. Behavioral and psychological symptoms of dementia. Front Neurology. 2012;0.
  7. Mukherjee A, Biswas A, Roy A, Biswas S, Gangopadhyay G, Das SK. Behavioural and psychological symptoms of dementia: correlates and impact on caregiver distress. Dementia Geriatric Cognitive Disorder Extra. 2017;7(3):354-365.
  8. Peters ME, Schwartz S, Han D, Rabins PV, Steinberg M, Tschanz JT, Lyketsos CG. Neuropsychiatric symptoms as predictors of progression to severe Alzheimer's dementia and death: the Cache County Dementia Progression Study. Am J Psychiatry. 2015 May;172(5):460-5.
  9. Gerlach LB, Kales HC. Managing Behavioral and Psychological Symptoms of Dementia. The Psychiatric clinics of North America. 2018 Mar;41(1):127-139.
  10. Best Practice Advocacy Centre NZ. Managing the behavioural and psychological symptoms of dementia; April 2020.
  11. 11. Laver K, Milte R, Dyer S, Crotty M. A Systematic Review and Meta-Analysis Comparing Carer Focused and Dyadic Multicomponent Interventions for Carers of People With Dementia. J Aging Health. 2017;29(8):1308-1349.
  12. Commonwealth of Australia. Royal Commission into Aged Care Quality and Safety. Interim Report: Neglect. Commonwealth of Australia; 2020.
  13. Australian Health Ministers Advisory Council. National Framework for Action on Dementia 2015. 2019.
  14. Cloak N, Al Khalili Y. Behavioral And Psychological Symptoms In Dementia. In: Treasure Island (FL): StatPearls Publishing; 2022 Jan.
  15. Van der Linde R, Stephan B, Dening T, CBrayne C. Instruments to measure behavioural and psychological symptoms of dementia. International Journal of Psychiatry Research. 2014;23(1):69-98.
  16. Guideline Adaptation Committee. Clinical Practice Guidelines and Principles of Care for People with Dementia. Sydney. Guideline Adaptation Committee; 2016.
  17. Reeves S, Mclachlan E, Bertrand J, D’Antonio F, Brownings S, Nair A, et al. Therapeutic window of dopamine D2/3 receptor occupancy to treat psychosis in Alzheimer’s disease. Brain. 2017;140(4):1117-27.
  18. Burns K, Jayasinha R, Tsang R, Brodaty H. Behaviour management a guide to goodpractice: managing behavioural and psychological symptoms of dementia; 2012.
  19. Liperoti R, Pedone C, Corsonello A. Antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD). Current neuropharmacology. 2008;6(2):117-24.
  20. Davies SJC et al. Sequential drug treatment algorithm for agitation and aggression in Alzheimer’s and mixed dementia. Journal of Psychopharmacology. 2018;32(5): 509-523.
  21. Chen A et al. The psychopharmacology algorithm project at the Harvard South Shore Program: an update on the management of behavioural and psychological symptoms of dementia. Psychiatry Research. 2021;295(113641).
  22. Ohno Y, Kunisawa N &Shimizu S. Antipsychotic treatment of behavioral and psychological symptoms of dementia (BPSD): management of extrapyramidal side effects. Front Pharmacol. 2019;10:1045.
  23. Working together with families and carers: Chief Psychiatrist’s guideline: Victorian Government.
  24. Stanbridge RI, Burbach FR, Rapsey EHS, Leftwich SH, McIver CC. Improving partnerships with families and carers in in-patient mental health services for older people: a staff training programme and family liaison service. Journal of Family Therapy. 2013;35(2):176-97.
  25. Wright M. Review of seclusion, restraint and observation of consumer with a mental illness in NSW Health facilities. December 2017.
  26. National Mental Health Commission. A case for change: Position paper on seclusion, restraint and restrictive practices in mental health services. May 2015.

Disclaimer

This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances or information or material that may have become subsequently available.