AC FFC Tidbit of the Week for May 15, 2022: Antipsychotics and people with dementia: When the risks outweigh the benefits

People with dementia can sometimes become agitated, especially when they are in unfamiliar surroundings, with unfamiliar people, and feeling powerless…like when they’re in the hospital.

Sometimes, the first course of action to manage someone who is highly agitated in an acute care setting is to give them an antipsychotic medication. But giving antipsychotics to older adults with dementia carries significant risks, including an increased risk of death. There is a black box warning and risk of death associated with these medications when used with older adults with dementia.

Here are answers to three common questions about the use of antipsychotics:

For what conditions are antipsychotics approved for use by the Food and Drug Administration?

Bipolar disorder (not an exclusion from denominator), schizophrenia, adjunct to antidepressants for major depressive disorder (aripiprazole), Tourette’s syndrome (conventional antipsychotics only), and Huntington’s disease.

What risks are associated with taking an antipsychotic?

Falls and fracture; sedation; delirium; functional decline; extrapyramidal symptoms (Parkinsonism, dyskinesias); anticholinergic side effects (orthostatis, constipation, blurry vision, etc.); hyperglycemia; hyperlipidemia; drug interaction (40% chance); pneumonia; cardiovascular risks; and death (mortality is highest in first 30-40 days).

What are some non-pharmacological alternatives to antipsychotics?

Rule out medical cause (delirium screening, vigilant medical care); address unmet needs (Are they in pain? Thirsty? Need to use the toilet?); communication strategies; routine & constituency with activities and caregivers; environmental modifications; maximize sensory input (glasses, hearing aids, plenty of light); involve in functional & physical activities; incorporate personal preferences; supervision & safety; and specific therapies such as art, music, aromatherapy, etc.

These non-pharmacological approaches are things we’ve talked about in previous tidbits, and can often be effective. It requires critical thinking and teamwork, but when it works, it not only helps the patient avoid the adverse effects of medication, it’s fulfilling for the caregiving team too! By putting yourself in the patient’s shoes to understand and empathize with what they are feeling (and fearing!), you can often help calm a person who is agitated.

Finally, here’s a helpful overview developed by the American Geriatrics Society and Consumer Reports that you may also want to share with a patient’s family members:

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