Behavioral and psychological symptoms pose a greater challenge than cognitive decline for dementia patients and their caregivers. These symptoms include aggression, agitation, and psychosis, and are experienced by 90% of dementia patients. There are evidence-based guidelines for assessing and treating these symptoms, including only using antipsychotic medication if symptoms are severe and causing significant distress, starting at a low dose and titrating up slowly, and discontinuing medication if no response after 4 weeks. However, medications are often continued for months or years after the original symptoms have stopped. Studies show that for most patients, discontinuing antipsychotics does not typically cause a return of symptoms, and the risks of ongoing treatment usually outweigh the benefits.

1. Poças, A.; Almeida, S. – Centro Hospitalar de Leiria; Portugal
Behavior disorders and psychosis may pose a greater challenge than cognitive decline for patients with dementia
and their caregivers. 90% of people with dementia experience behavioural and psychological symptoms such as
aggression, agitation and psychosis.. These symptoms can be distressing and a threat to the person and their
caregivers.
There are evidence-based recommendations to assess psychological and behavioral symptoms of dementia and
perform a risk/benefit analysis before prescribing an antipsychotic. The Practice Guidelines of American
Psychiatric Association (APA) includes recommendations with moderate and low strength of supporting research
evidence regarding antipsychotic use to treat agitation or psychosis in patients with dementia. Here we show the
ones with moderate strength of supporting:
• Only use nonemergency antipsychotic medication when agitation and
psychosis symptoms are severe, are dangerous, and/or cause significant
distress to the patient.
• If a risk/benefit assessment favors the use of an antipsychotic for
behavioral/psychological symptoms in patients with dementia, start treatment at
a low dose and titrate up to the minimum effective dose as tolerated.
• If there is no clinically significant response after a 4-week trial of an adequate
dose of an antipsychotic drug, the medication should be tapered and
withdrawn.
• In the absence of delirium, if nonemergency antipsychotic medication treatment
is indicated, haloperidol should not be used as a first-line agent.
• A long-acting injectable antipsychotic medication should not be utilized unless it
is otherwise indicated for a co-occurring chronic psychotic disorder.
Most of the times, the agents continue to be prescribed for months/ years, long after the original symptoms have
stopped. The recommendation of discontinuing medication after 4 months may seem counterintuitive when the patient
is doing well but the studies showed that a large fraction of individuals with dementia can discontinue antipsychotics
without a return of their agitation or psychosis. For most patients, the risk of ongoing harm outweighs the benefits of
continuing treatment, and these individuals will never be identified if a clear protocol for withdrawal is not routinely
used.
Bibliography :
The Practice Guidelines of American Psychiatric Association
Victor R, Laura F, et al: The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. The American Journal of Psychiatry 2016
Agency for Healthcare Research and Quality: Methods Guide for Effectiveness and Comparative Effectiveness Reviews 2014
Andrews C, Schünemann J, et al: GRADE guidelines: 15. Going from evidence to recommendation: determinants of a recommendation’s direction and strength. J Clin Epidemiol 2013