1.3. Explain the risks and benefits of anti-psychotic medication for individuals with dementia

This guide will help you answer 1.3. Explain the risks and benefits of anti-psychotic medication for individuals with dementia.

Antipsychotic medication can change how the brain processes signals that affect mood, thoughts, and behaviour. In dementia care, some individuals develop symptoms such as aggression, agitation, delusions, or hallucinations. Antipsychotics are sometimes used to help with these problems.

Common antipsychotic drugs include risperidone, quetiapine, and olanzapine. Haloperidol, an older drug, is less used today due to side effects.

Deciding to give antipsychotics to a person with dementia is a very serious step. Medicines should only be given when absolutely necessary and always under medical supervision.

Why Antipsychotic Medication May Be Used

People with dementia can show concerning behaviours known as behavioural and psychological symptoms of dementia (BPSD). These might include:

• Agitation (restlessness, pacing, fidgeting)
• Aggression (shouting, hitting, or lashing out)
• Hallucinations (seeing or hearing things not present)
• Delusions (firm beliefs in things that are untrue)
• Anxiety
• Distress

Sometimes, these symptoms make it hard for carers to provide safe and supportive care. Non-drug approaches, such as changes to the person’s environment or personalised care, are the first choice. Antipsychotics are only used if these ways are not helping, or when symptoms put the person or others at risk.

Benefits of Antipsychotic Medication

When used carefully, antipsychotics can offer some benefits for people with dementia, particularly for severe symptoms.

Control of Aggressive or Dangerous Behaviour

• Reduces extreme aggression that may cause harm.
• Helps staff and families manage care more safely.
• May allow the person to remain in their own home, if alternative would have been hospital admission.

Relief from Distressing Symptoms

• Can lower the intensity of frightening hallucinations or delusions.
• Might help the person feel calmer, less anxious, and settled.

Support for Care Relationships

• Supporting family and staff. If extreme behaviour improves, relationships may become less strained.
• Reduces stress on carers and environment.

Short-term Use Benefits

• Medicines may be helpful in the short term if someone is very distressed, frightened, or a danger to themselves or others.
• Allows time for further assessment or changes to the care plan.

Antipsychotics are most helpful for managing psychosis (delusions and hallucinations) and severe aggression which other methods have not improved.

Evidence of Effectiveness

Research shows that antipsychotics may work for some people, mainly for aggression and serious psychotic symptoms. At best, effects are often moderate and may not last over long periods.

Guidelines suggest prescribing the lowest dose, for the shortest possible time, with regular review.

Risks of Antipsychotic Medication

Antipsychotics can have serious side effects in people with dementia. The risks must be weighed against any benefits.

Increased Risk of Stroke and Death

Research shows a higher chance of stroke in older adults with dementia using antipsychotics. The increase may not be high for one person, but across a group, the risk is there.

• Two to three times increased risk of stroke.
• Some studies link antipsychotics with a higher risk of death (about 1 in 100 annual risk), especially when used for a long time or at higher doses.

Sedation and Reduced Mobility

People taking these drugs often feel very sleepy or drowsy.

• May lead to increased risk of falls and fractures.
• Can cause confusion, which may worsen dementia symptoms.

Extrapyramidal Side Effects

This describes movement problems caused by medicine disturbing dopamine signals in the brain.

• Symptoms include rigidity, tremor, restlessness, and involuntary movements (commonly called parkinsonism).
• People may shuffle when walking or feel stiff.

Worsening Memory and Thinking

Antipsychotics may make memory, thinking, or communication slower and less clear. In some cases, this can push a mild dementia into a more severe state.

Other Physical Risks

• Weight gain, diabetes.
• Problems regulating temperature.
• Low blood pressure (dizziness, risk of falls).
• Heart rhythm problems, sometimes detected by changes on an electrocardiogram (ECG).
• Increased risk of chest infections.
• Constipation, which can sometimes be severe.

Emotional and Quality of Life Impact

• Person may appear ‘flattened’, less engaged, withdrawn, or have reduced interest in activities.
• Reduced sense of self.
• Problems with daily activities because of drowsiness or movement difficulties.

Dependency and Withdrawal

If taken for a long time, stopping the medicine may cause withdrawal symptoms. This may include renewed agitation, symptoms returning worse, or physical discomfort.

Monitoring and Review

Prescribers should always review antipsychotic use in people with dementia. Checks include:

• Looking for improvements in symptoms.
• Watching for side effects – falls, sleepiness, infections, loss of mobility.
• Considering whether non-drug options might now help.
• If no clear benefit after a short time, stopping consideration.

Most guidelines recommend review after 6–12 weeks of use, and stopping wherever possible.

Best Practice and Alternatives

Antipsychotics should only be tried after other support methods have not worked. Best practice recommends:

• Complete an assessment of possible causes of symptoms (pain, infection, environment, changes in behaviour triggers).
• Try non-drug approaches first, such as adapted communication, meaningful activities, and improving environments.

Non-Drug Alternatives

• Understanding personal history and triggers.
• Good physical health (treat pain, eye or ear problems, constipation, hunger or thirst).
• Supportive communication.
• Structured routines.
• Helping the individual maintain independence and promote their dignity.
• Using music, art, reminiscence, or sensory activities.

In some situations, a short course of antipsychotics is agreed by the care team, the prescriber, the individual (where they can give consent), and their family or next-of-kin.

Key Points to Share with Families and Individuals

Family members often worry when antipsychotics are mentioned. Good communication is important. You can explain:

• Why the medicine is being considered, after other ways did not help.
• What the benefits might be, such as calming distress or controlling aggression.
• What the risks are, including the side effects and possible long-term harm.
• The plan to use as low a dose as possible and review treatment quickly.
• That these drugs do not treat the underlying dementia or slow its progress.
• Monitoring of the person, with changes to the plan if problems arise.

Consent is vital where the individual can be involved in decisions. If not, a best-interest meeting following the Mental Capacity Act must take place.

Government and Local Guidance

National guidelines, such as those from the National Institute for Health and Care Excellence (NICE), say antipsychotic medicines:

• Should not be first choice for managing agitation or aggression in dementia.
• Only be prescribed for severe symptoms putting self or others at urgent risk.
• Always be used with careful monitoring and be reviewed regularly.

CQC inspections and safeguarding teams take a keen interest in how organisations manage antipsychotic use, expecting robust review and consent procedures.

Balancing Decisions

Each person with dementia is different. Responses to antipsychotics vary – some improve, others have no change, or get worse. Weighing the risks and benefits is a shared decision between doctors, care staff, families, and the individual.

If an antipsychotic is used, keep the following in mind:

• Use only for clear, urgent need.
• Stay at the lowest possible dose.
• Use only for the shortest time necessary.
• Review regularly, aiming to stop where safe.

Transparency, documentation, and teamwork are needed to promote safe, person-centred care.

Final Thoughts

For individuals with dementia, antipsychotic medication offers some short-term relief for severe behavioural and psychological symptoms, especially aggression and psychosis. The drugs can help when someone’s safety is at risk, or if other measures do not work. Still, the risks are serious and common—stroke, increased death, sedation, loss of quality of life, more confusion, heart problems, and infections.

Medicines should always be a last resort, used only under careful medical guidance, with full discussion between care staff, health professionals, the person, and their family. Regular review is expected. If no benefit is seen, or side effects develop, the medicine should be stopped where possible.

Non-drug approaches are safer and more helpful for most people with dementia. Staff need training and support to put these into practice. Good communication, careful risk-benefit assessment, and regular review help safeguard people and promote well-being.