How to use anti-psychotic medication in dementia:

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1 How to use anti-psychotic medication in dementia: An Information guide for person living with dementia or their carers NHS Lewisham Clinical Commissioning Group 1

2 Dementia Dementia describes a set of symptoms that affect the normal functions of the brain. These symptoms include declining memory loss, difficulties with thinking, problem solving, language impairment and disorientation as well as impairment in one s ability to carry out activities of daily living. Frequently asked questions about anti-psychotic medication in dementia What are anti-psychotic medicines? How does dementia affect the person s behaviour? People living with dementia sometimes develop behavioural and psychological symptoms such as restlessness, agitation, aggression, mood disorders, wandering and sexual disinhibition. Other symptoms associated with mental health conditions such as psychosis can also occur including hearing voices, seeing visions (hallucinations) or abnormal beliefs (delusions). These symptoms can become distressing both for the person with dementia and their carer(s). Managing challenging behaviour in Dementia Medication is not the first line treatment for aggressive behaviour. It is important to manage the cause of the distress leading to the behaviour (which may for example be pain, loneliness, or frustration and the inability to communicate particularly where speech is affected in cognition). However where the behaviours put the person or others at risk, it may become necessary to consider medication to manage such symptoms. A variety of medicines have been tried for these symptoms including antipsychotic medication. Image of brain affected by dementia How to use this guide This guide contains information about the use of anti-psychotic medication in dementia. It should be used in conjunction with national guidelines which can be found at Any further questions or concerns about dementia or medication for dementia should be referred to the mental health team or the GP looking after your relative/ friend or the person you are supporting. Anti-psychotics are a group of medicines that are usually used to treat people with mental health conditions such as schizophrenia. They are sometimes used for people with dementia if they have persistent behaviour and psychological symptoms that are distressing to the individual or others and significantly impairing quality of life. They are powerful drugs which have many side effects. When should anti-psychotic medicines be used in dementia? Anti-psychotic medicines should only be used if absolutely necessary. Only a doctor can prescribe the medicines following discussion and agreement with family, carers and the person with dementia. Anti-psychotic medicine maybe prescribed if the target symptom is aggression to others, the behaviour has no clear situational trigger and treatment is needed quickly. It can also be prescribed as treatment in the management of delirium which should be stopped when delirium is resolved. 2 How to use anti-psychotic medication in dementia NHS Lewisham Clinical Commissioning Group 3

3 Which anti-psychotics are used in dementia? ** Risperidone is the only anti-psychotic medication specifically licensed for (up to 6 weeks) for the treatment of persistent aggressive behaviour, unresponsive to non-drug treatments in a type of dementia called Alzheimer s dementia. Doctors can prescribe other anti-psychotic medicines if they consider appropriate. All anti-psychotic medicines carry similar risks when used in people with dementia and so they should all be used in low doses for short period of time and discontinued when possible. What are the effects of anti-psychotic medicines? What alternative treatments can be used in dementia? Behavioural and psychological symptoms in dementia often respond to non-drug treatments that are person-centred. These can include reassurance, distraction with meaningful activities such as relaxation and psychological therapies. In most cases, these interventions are effective approaches for managing these symptoms. Examples of non-drug treatments include: Engaging in short conversation with the person (just a 30 second chat can make a big difference) Holding the person s hand or gently stroking their arm while reassuring them. Leave and return Offering soothing and creative therapies such as aromatherapy, massage, grooming like having their hair brushed or a manicure, warm towel, music and dance therapy. Involving friends or family by sharing information about the person s likes and dislikes. Including the person s wishes in their care. If non-drug approaches have not worked, anti-psychotic medication can be prescribed for a short period. Anti-psychotic medication is not beneficial in behaviours such as vocalisation (screaming or calling out), pacing up and down or anxiety and distress when someone is being cared for. Anti-psychotic medication may however be appropriate as a first response where the target symptom is aggression to others and the behaviour has no clear situational trigger and treatment is needed quickly. Anti-psychotic medication aims to relieve the target symptoms of aggression, delusions and /or hallucinations so that the person living with dementia will feel calmer, less distressed, more able to interact socially and to engage in activities. How long will anti-psychotic medication take to work? Anti-psychotic medication may produce some noticeable effects within a few hours but the full benefits of medication may take some weeks to develop. How will the dose be decided? The Committee of Safety of Medicines in the UK, advises that anti-psychotic medicines should only be used when considered absolutely necessary, at the lowest effective dose for the shortest possible period of time, and subject to regular review. Therefore anti-psychotic medicines should be prescribed at a very low starting dose and increased very slowly and carefully with full evaluation of both the benefits and side-effects at regular intervals. Like all drugs, anti-psychotic medicines have possible side-effects and these will normally be related to the dose prescribed. 4 How to use anti-psychotic medication in dementia **at the time of publication of this leaflet, Risperidone was the only anti-psychotic medication specifically licensed for dementia.

4 Can other medicines be used in dementia? Other medicines can be used in dementia to treat depression, anxiety, sleep disturbance, agitation and aggression. These may include antidepressants, sleeping tablets, antiepileptics, pain killers and anxiety medication. Anti-dementia medicines may be used for the memory decline itself and help with orientation/alertness/motivation in dementia. However, the anti-dementia medicines are not often effective on their own against the more severe behavioural symptoms of dementia. Some people living with dementia will need a combination of interventions to manage their symptoms. All medicines prescribed for a person with dementia will be agreed with the person and/or their carers following a careful individual assessment/review of their changing needs by specialist. Is there any follow-up? The prescribing doctor will follow-up with the patient and carers. It will only be used for as long as is absolutely necessary. Trials of stopping the medication will be suggested to see whether or not the target symptoms return. Where possible, the person living with dementia and their family /carers should be involved in decisions about any treatment. Are there any side-effects? Common side-effects of anti-psychotic medicines include drowsiness, dizziness, unsteadiness, shaking and joint stiffness. Sometimes the prescribing of anti-psychotic medicines is associated with increased agitation and worsening confusion and the dose may have to be reduced, changed or even discontinued. Are there any serious risks associated with taking anti-psychotic medicines in dementia? The potential dangers of using anti-psychotic medication in people with dementia includes Sedation Increased risk of falls Increased risk of stroke and rarely sudden premature death Accelerated decline in the person s ability to function e.g. processing information, memory, attention and concentration etc. The benefits of trying an anti-psychotic medication in a person living with dementia should be carefully weighed against the possible risks and side-effects of the treatment. The prescribing of anti-psychotic medicines should not interrupt the treatment of any other mental health conditions. You have the right to ask questions at any time Please remember that you have the right to ask questions and find out more. Below are a few questions you may want to ask your prescribing doctor. Has the patient had a medical review recently? Is there a care plan? Is it tailored to the individual s wishes and needs? How is the care plan used? Can I share the person s likes and dislikes, and add to the care plan? What signs should I be looking out for to help stop their symptoms getting worse? What non-drug approaches have been tried? How long has the person already been on antipsychotic medication? Is it in the person s best interest to have antipsychotic medication? Key Points People living with dementia and their family /friends and /or carers should be involved in treatment decisions where possible. In many cases, behavioural and psychological symptoms of dementia such aggression and agitation often improve without the need for medication. Anti-psychotic medication should be used only as a last resort, at lowest possible dose for shortest duration, no longer than 12 weeks except in extreme circumstances. 6 How to use anti-psychotic medication in dementia NHS Lewisham Clinical Commissioning Group 7

5 Useful information and websites For more information about dementia you can visit the following websites: NHS Choices: Alzheimer s Society: Dementia UK: For more information about the use of anti-psychotic medicines you can visit the following websites: For information about mental illness including psychosis you can visit rethink website: This guide has been produced by NHS Lewisham Clinical Commissioning Group, in partnership with Lewisham Mental Health Care Home Intervention Team, South London and Maudsley NHS Trust Follow If you require this information in an alternative format please contact Christine Banwell, NHS Lewisham CCG.