Behavioral problems like aggression, agitation, and hallucinations are often treated with medications called “antipsychotics” or “neuroleptics.” Newer medications in this class include Risperdal, Zyprexa, Geodon, Seroquel, and Abilify. Older medications, including Thorazine, Haldol, and Melleril, are not widely used today.

The benefits of these medications are modest at best. However, the list of adverse effects continues to grow. A recent study adds to the concerns with use of these medications to treat behavioral problems associated with dementia. Antipsychotic medications caused significant decline in remaining cognitive skills. There was a significant drop in neuropsychological test scores when compared to placebo after 12 weeks of treatment. It is unclear from the results whether the decline is permanent and would be reversed by cessation of the drugs.

This adds another element to the growing concern over the use of antipsychotic medications to manage behavioral problems in people with a diagnosis of dementia.
The FDA has already added a “black box” warning that antipsychotic medications produce significant risk of life threatening side effects. Older as well as newer medications increase the risk of death – especially at higher doses.

Treatment with antipsychotics (including newer medications) has been associated with weight grain, hyperglycemia (high blood sugars), increased risk for stroke and transient ischemic attacks (TIAs), dysfunctions of cardiac conduction, pneumonia, movement disorders such as tardive dyskinesia, hyperlipidemia (high blood fats), worsening of diabetes, and increased risk for metabolic syndrome and diabetes. These finding raise questions about the relative benefits and costs of these medications.

Currently, only Risperdal is approved for use with dementia patients and only in low doses for up to 6 weeks. Other medications are “off label” for this use and at the discretion of a physician. Antipsychotic medications should be used with caution and vigilance and only if other nonmedication approaches have been shown not to work or if the behavioral issues cause danger to self or others. Antipsychotics should be used only after careful consultation with your physician and only with the informed consent of legal representatives.

Careful cardiac evaluation needs to be done before and after prescribing antipsychotic medications to better determine the risk versus the benefits of use. Blood sugars, lipids and weight should be monitored prior to and subsequent to prescribing these medications. Family members should be vigilant for over sedation or gait changes. Antipsychotic medications should be carefully discontinued when they are no longer needed as there may withdrawal effects and these medications should not be suddenly discontinued.

Difficult behaviors need to be managed through environmental (e.g., keeping people with memory loss engaged, confrontation only if the behavior causes a risk) and behavioral control interventions (e.g., calming voice, redirection toward peaceful activity). These interventions are not as convenient but are much safer.