The Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia

Publication Date: May 1, 2016
Last Updated: March 2, 2023

Guideline Statements

Assessment of Behavioral/Psychological Symptoms of Dementia

APA recommends that patients with dementia be assessed for the type, frequency, severity, pattern, and timing of symptoms. (1, C)
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APA recommends that patients with dementia be assessed for pain and other potentially modifiable contributors to symptoms as well as for factors, such as the subtype of dementia, that may influence choices of treatment. (1, C)
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APA recommends that in patients with dementia with agitation or psychosis, response to treatment be assessed with a quantitative measure. (1, C)
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Development of a Comprehensive Treatment Plan

APA recommends that patients with dementia have a documented comprehensive treatment plan that includes appropriate person-centered nonpharmacological and pharmacological interventions, as indicated. (1, C)
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Assessment of Benefits and Risks of Antipsychotic Treatment for the Patient

APA recommends that nonemergency antipsychotic medication should only be used for the treatment of agitation or psychosis in patients with dementia when symptoms are severe, are dangerous, and/or cause significant distress to the patient. (1, B)
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APA recommends reviewing the clinical response to nonpharmacological interventions prior to nonemergency use of an antipsychotic medication to treat agitation or psychosis in patients with dementia. (1, C)
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APA recommends that before nonemergency treatment with an antipsychotic is initiated in patients with dementia, the potential risks and benefits from antipsychotic medication be assessed by the clinician and discussed with the patient (if clinically feasible) as well as with the patient’s surrogate decision maker (if relevant) with input from family or others involved with the patient. (1, C)
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Dosing, Duration, and Monitoring of Antipsychotic Treatment

APA recommends that if a risk/benefit assessment favors the use of an antipsychotic for behavioral/psychological symptoms in patients with dementia, treatment should be initiated at a low dose to be titrated up to the minimum effective dose as tolerated. (1, B)
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APA recommends that if a patient with dementia experiences a clinically significant side effect of antipsychotic treatment, the potential risks and benefits of antipsychotic medication should be reviewed by the clinician to determine if tapering and discontinuing of the medication is indicated. (1, C)
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APA recommends that in patients with dementia with agitation or psychosis, 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. (1, B)
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APA recommends that in a patient who has shown a positive response to treatment, decision making about possible tapering of antipsychotic medication should be accompanied by a discussion with the patient (if clinically feasible) as well as with the patient’s surrogate decision maker (if relevant) with input from family or others involved with the patient. The aim of such a discussion is to elicit their preferences and concerns and to review the initial goals, observed benefits and side effects of antipsychotic treatment, and potential risks of continued exposure to antipsychotics, as well as past experience with antipsychotic medication trials and tapering attempts. (1, C)
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APA recommends that in patients with dementia who show adequate response of behavioral/psychological symptoms to treatment with an antipsychotic drug, an attempt to taper and withdraw the drug should be made within 4 months of initiation, unless the patient experienced a recurrence of symptoms with prior attempts at tapering of antipsychotic medication. (1, C)
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APA recommends that in patients with dementia whose antipsychotic medication is being tapered, assessment of symptoms should occur at least monthly during the taper and for at least 4 months after medication discontinuation to identify signs of recurrence and trigger a reassessment of the benefits and risks of antipsychotic treatment. (1, C)
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Use of Specific Antipsychotic Medications, Depending on Clinical Context

APA recommends that in the absence of delirium, if nonemergency antipsychotic medication treatment is indicated, haloperidol should not be used as a first-line agent. (1, B)
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APA recommends that in patients with dementia with agitation or psychosis, a long-acting injectable antipsychotic medication should not be utilized unless it is otherwise indicated for a co-occurring chronic psychotic disorder. (1, B)
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Recommendation Grading

Overview

Title

The Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia

Authoring Organization

American Psychiatric Association

Publication Month/Year

May 1, 2016

Last Updated Month/Year

August 1, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Long term care

Intended Users

Psychologist, paramedic emt, nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D003704 - Dementia

Keywords

dementia, psychosis, Agitation

Methodology

Number of Source Documents
207
Literature Search Start Date
February 1, 2013
Literature Search End Date
January 1, 2015