Choosing Wisely:

Don’t prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia without an assessment for an underlying cause of the behavior.

Rationale and Comments: Careful differentiation of cause of the symptoms (physical or neurological versus psychiatric, psychological) may help better define appropriate treatment options. The therapeutic goal of the use of antipsychotic medications is to treat patients who present an imminent threat of harm to self or others, or are in extreme distress–not to treat nonspecific agitation or other forms of lesser distress. Treatment of BPSD in association with the likelihood of imminent harm to self or others includes assessing for and identifying and treating underlying causes (including pain; constipation; and environmental factors such as noise, being too cold or warm, etc.), ensuring safety, reducing distress and supporting the patient’s functioning. If treatment of other potential causes of the BPSD is unsuccessful, antipsychotic medications can be considered, taking into account their significant risks compared to potential benefits. When an antipsychotic is used for BPSD, it is advisable to obtain informed consent.
Sponsoring Organizations:
  • American Medical Directors Association
  • Sources:
  • American Medical Directors Association guidelines and systematic reviews
  • Disciplines:
  • Geriatric Medicine
  • Psychiatric and Psychologic
  • References: • American Medical Directors Association. Dementia in the long-term care setting clinical practice guideline. Columbia, Md.: AMDA 2012.
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    • American Medical Directors Association. Delirium and acute problematic behavior clinical practice guideline. Columbia, Md.: AMDA 2008.
    • Ozbolt LB, Paniagua MA, Kaiser RM. Atypical antipsychotics for the treatment of delirious elders. J Am Med Dir Association. 2008;9:18-28.
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    • U.S. Food and Drug Administration, U.S. Department of Health and Human Services. 2007 information for healthcare professionals: haloperidol (marketed as Haldol, Haldol decanoate, and Haldol lactate) [Internet]. 2007 Sep 17 [cited 2013 Jul 23]. Available from: http://www.fda.gov/cder/drug/InfoSheets/HCP/haloperidol.htm.
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    • Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia. N Engl J Med. 2005 Oct 19;294(15):1934-43.
    • Schneider LS, Tariot PN, Dagerman KS. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355(15):1525-38.
    • Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA. 2005;293:596-608.
    • U.S. Food and Drug Administration, U.S. Department of Health and Human Services. FDA public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances [Internet]. 2005 Apr 11. [cited 2013 Jul 23]. Available from: http://www.fda.gov/cder/drug/advisory/antipsychotics.htm.
    • Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934-1943.

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