The overall benefit of antipsychotics in BPSD is small and is limited by their side-effect. In general, in most situations, the benefits of antipsychotics are far out-weighed by their risk.
Antipsychotics have a multitude of adverse effects and should be avoided where possible. They can
- increase the risk of death (~ x 2)
- increase the risk of stroke (~ x 3).
- increase risk of falls and drowsiness- resulting in increased injuries such as hip fractures
- they have an impact on swallowing which can result in an aspiration pneumonia
The use of antipsychotics should be reserved for use in severe aggression or agitation where there is a risk to self or others.
Risperidone is the only licensed antipsychotic in people with dementia. Its license is for the short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others. Watch out for extrapyramidal effects.
- Starting dose of risperidone is 0.25 – 0.5 mg/day.
- Some patients can respond to a very low dose of antipsychotic, so start low and go slow
- Maximum recommended dose of risperidone is 2mg/day.
Monitoring of Antipsychotic Prescribing
If you do prescribe an antipsychotic then it needs to be reviewed regularly (see monitoring tool below)
- Initial review should occur one week after starting it.
- Extra-pyramidal side effects can emerge within days with impact on gait & swallowing difficulties
- If there is no clinically significant response after a 4 week trial of an adequate dose then the antipsychotic should be tapered down and withdrawn.
- If there has been an adequate response to treatment then an attempt to taper and withdraw should be made within 4 months of initiation.
- Some patients do end up needing long term antipsychotic prescriptions but these prescriptions need to be monitored regularly.