Pharamalogical interventions
With behavioural and psychological symptoms of dementia (BPSD) look for activating causes and contributing medical issues.
Investigate and treat pain.
Antipsychotic medication should be used judiciously for problems that actually need treatment i.e. high risk or marked distress.
Seek non-pharmacological interventions in the first instance.
Use antipsychotic medication in an evidence based manner, using the lowest effective dose possible.
All antipsychotics are known to have adverse effects and increase the risk of stroke. AVOID in Lewy Body Dementia. Frequent monitoring is essential.
In most patients, institute a trial of discontinuation after 6 to 12 weeks treatment.
Atypical antipsychotics work best for hallucinations, delusions, aggression and psychosis. They are not usually effective for symptoms of calling out, wandering, pacing or resisting care unless the patient is over-sedated.
Antipsychotic treatment principles
Always use antipsychotic medications in the context of a comprehensive care plan:
- Person-centred and family-centred approaches
- Tailored diversional activities
- Flexible routines to minimise resistance to care
- Prosthetic environment designed specifically for people with dementia
- Room for physical activity to assist those with motor overactivity e.g. pacing or wandering
Use of antipsychotic medications in dementia
- Obtain consent from substitute decision maker
- Consider risk factors for adverse effects
- Determine a stopping rule at initiation of drug
- Do not expect immediate results from low-dose antipsychotic medication*
- Use very low-dose Risperidone (0.25mg - 0.5mg once daily initially)
- Give regularly rather than PRN (there is no real evidence on PRN antipsychotics in older people)
- Maintain hydration and check for postural BP drop
- Monitor for Parkinsonism (can develop late)
- Check for other adverse effects
- In general, do not exceed 2mg/day Risperidone (most patients only need 1mg/day; an occasional highly agitated younger person with dementia may need more than 2mg/day)
- Cease drug if ineffective
*If immediate results are required, then higher doses are often required. These higher doses have attendant higher risks and impose a much higher duty of care. Often patients will need one to one nursing to minimise risk of falls and aspiration.
Significant adverse effects of antipsychotic medication
There are significant adverse effects which include:
- Parkinsonism
- Falls
- Hip fractures
- DVT
- Cognitive impairment
- Cardiovascular
- Cerebrovascular
- Death
Information courtesy of Associate Professor Mark Yates, Consultant Geriatrician, Meredith Theobald, Director of Nursing Subacute Services and Michelle Morvell, CNC Cognition, Ballarat Health Services: Dementia Care in Hospitals Program