APA Releases New Practice Guidelines on the Use of Antipsychotics in Patients with Dementia

APA Releases New Practice Guidelines on the Use of Antipsychotics in Patients with Dementia

ARLINGTON, Va. – Today the American Psychiatric Association (APA) released new evidence-based recommendations on the use of antipsychotics to treat agitation or psychosis in patients with dementia. The guidelines include recommendations for assessment of psychological and behavioral symptoms of dementia, development of a comprehensive treatment plan, assessment of the benefits and risks of antipsychotics, and judicious use of antipsychotics, including specifics for dosing, duration and monitoring.

The population of elderly patients, including those with dementia, is growing and an overwhelming majority of older adults with dementia will develop psychosis or agitation during their illness. Treatment of these symptoms has often involved use of antipsychotic medications. However, in recent years, evidence from clinical trials shows little benefit from using antipsychotic medications with these patients and the antipsychotics are associated with significant adverse effects, including increased risk of cognitive decline and increased risk of death.

“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,” said APA President Renée Binder, M.D.

The new guidelines provide the latest extensively reviewed evidence to help clinicians, individuals, caregivers and others make informed decisions.

Among the new recommendations:

  • Non-emergency antipsychotic medication should only be used in patients with dementia when agitation and psychosis symptoms are severe, are dangerous and/or cause significant distress to the patient.
  • Response to non-drug interventions should be reviewed prior to use of antipsychotic medication.
  • Before treatment with an antipsychotic, the potential risks and benefits should be assessed by the physician and discussed with the patient and the patient’s surrogate decision maker, with input from the family.
  • Treatment should be initiated at a low dose and eased up to the minimum effective dose.
  • If the patient experiences significant side effects, the risks and benefits should be reviewed to determine if the antipsychotic should be discontinued.
  • If there is no significant response after a 4-week time period, the medication should be tapered and withdrawn.
  • In patients who show adequate response to the medication, an attempt to taper and withdraw the antipsychotic should be made within four months of starting.
  • In patients whose antipsychotic medications are being tapered, symptoms should be assessed at least every month during tapering and for at least four months after the medication is discontinued.
  • A long-acting injectable antipsychotic should not be used unless it is administered for a co-occurring chronic psychotic disorder.
  • If non-emergency antipsychotic medication treatment is to be used, haloperidol should not be used first.

While the focus of the guidelines is antipsychotic therapy, they emphasize that any such medication given to dementia patients should be just one part of a comprehensive treatment plan that is person-centered and includes appropriate drug and non-drug treatments.

The guidelines were developed by the APA Practice Guideline Writing Group. APA guidelines are developed using a process consistent with recommendations of the Institute of Medicine (IOM), the Agency for Healthcare Research and Quality (AHRQ), and the Council of Medical Specialty Society. More information on the process.

The Executive Summary of the guidelines appears in the May issue of The American Journal of Psychiatry (AJP). The full guideline will be available at PsychiatryOnline.

The American Psychiatric Association is a national medical specialty society whose more than 36,500 physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders.

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