Antipsychotics and older people

Frequently asked questions about the use of antipsychotic medicines in older people

Antipsychotic medicines are sometimes used for the behavioural and psychological symptoms of dementia if non-medication options have not worked.

Antipsychotic medicines must be used with caution in older people because they can cause serious harm. They need to be prescribed to the right people for the right reason and for the right period of time. Antipsychotics do work for many people, sometimes very well.

In older people, treatment should be as a trial at the lowest dose likely to provide benefit and should usually not be given for longer than 3 months, unless prescribed for a long-term mental health condition.

What are the concerns when using antipsychotic medicines in older people?

Older people are particularly at risk of serious side effects from antipsychotic medicines, eg, drowsiness, risk of falls, pneumonia (lung infection), stroke and heart problems. It is best that antipsychotic medicines are used at the lowest dose likely to provide benefit and for no longer than 3 months, unless prescribed for a long-term mental health condition. 

When are antipsychotic medicines used in older people?

Antipsychotics may be considered for people with behavioural and psychological symptoms of dementia (BPSD) if non-medication options have not worked. They may be used when aggression, agitation or psychotic symptoms are causing severe distress or when patients are at an immediate risk of harm to themselves or others. Antipsychotics are only mildly effective for managing BPSD, and the effectiveness varies between people. 

Antipsychotics are also used for people who have a pre-existing mental illness where antipsychotics are preferred.

When are antipsychotic medicines not useful?

Antipsychotics are not useful for treating symptoms such as wandering, shouting, touching or social withdrawal, or intermittent symptoms that are related to a specific trigger. Antipsychotics should be avoided if people have Lewy body dementia or Parkinson’s disease with dementia. 

Antipsychotic medicines are generally not recommended for anxiety or depression because of the risk of serious side effects. Other options for these conditions should be tried first.

Is there a preferred antipsychotic for use in older people?

Risperidone and quetipaine are currently the most commonly prescribed antipsychotic medicine for BPSD. Treatment should be started as a trial at the lowest dose likely to provide therapeutic benefit, and treatment should be reviewed regularly. If there has been no improvement in symptoms after a few weeks, the medicine should be withdrawn.

People who do respond to treatment should notice a difference within 3 months and withdrawal of treatment should be trialled. If the one trialled is not tolerated or appropriate, other antipsychotics may be considered.

Should antipsychotics be used for sleeping problems?

For older people who are having problems sleeping, antipsychotics should not be used. Sleep hygiene is the preferred treatment, such as establishing a bedtime routine, avoiding alcohol and stimulants before bedtime and not staying in bed when not sleeping. 

Learn more

Alzheimer’s disease – treating disruptive behaviour Choosing Wisely, NZ

References

  1. Managing the behavioural and psychological symptoms of dementia BPAC, NZ, 2020
  2. National report: The use of antipsychotic medicines in older people BPAC, NZ, 2020
Credits: Sandra Ponen, Pharmacist. Reviewed By: Angela Lambie, Pharmacist, Auckland and Dr Helen Kenealy, geriatrician and general physician, CMDHB Last reviewed: 30 Jun 2020