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Am Fam Physician. 2016;94(4):276-282

Related letter: Antipsychotic Use in Patients with Dementia with Lewy Bodies

Patient information: See related handout on behavior problems in patients with dementia.

Author disclosure: No relevant financial affiliations.

Behavioral and psychological symptoms of dementia pose management challenges for caregivers and clinicians. First-line nonpharmacologic treatments include eliminating physical and emotional stressors, modifying the patient's environment, and establishing daily routines. Family members and caregivers benefit from education about dementia symptoms and reminders that the behaviors are normal and unintentional. Cognitive and emotion-oriented interventions, sensory stimulation interventions, behavior management techniques, and other psychosocial interventions are modestly effective. In refractory cases, physicians may choose to prescribe off-label antipsychotics. Aripiprazole has the most consistent evidence of symptom improvement; however, this improvement is small. Olanzapine, quetiapine, and risperidone have inconsistent evidence of benefit. Physicians should use the smallest effective dose for the shortest possible duration to minimize adverse effects, most notably an increased mortality risk. Other adverse effects include anticholinergic and antidopaminergic effects, extrapyramidal symptoms, neuroleptic malignant syndrome, postural hypotension, metabolic syndrome, cardiac arrhythmia, and sedation. Patients should be monitored for these effects while receiving treatment; however, laboratory monitoring may be limited to patients receiving long-term therapy.

Behavioral and psychological symptoms of dementia pose management challenges for caregivers and clinicians. Although non-drug therapy is effective, Medicare drug claims in 14% of nursing home residents included atypical (second-generation) antipsychotic medication use for treating symptoms of dementia.1 This off-label use of antipsychotics occurs despite a U.S. Food and Drug Administration (FDA) boxed warning noting an increased risk of death when antipsychotics are used in patients with dementia-related psychosis.2 Because the estimated number of U.S. adults with dementia was 3.4 million in 2002 and is projected to double by 2025, primary care physicians should be familiar with nonpharmacologic management of dementia-related symptoms and with the effectiveness and risks of antipsychotic medications before initiating off-label use.35

RecommendationSponsoring organization
Do not prescribe antipsychotic medications for behavioral and psychological symptoms of dementia in individuals with dementia without an assessment for an underlying cause of the behavior.American Medical Directors Association
Do not use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.American Geriatrics Society American Psychiatric Association
Clinical recommendationsEvidence ratingReferences
Nonpharmacologic interventions should be used as first-line treatment for behavioral and psychological symptoms of dementia.C7, 13
Before initiating antipsychotic therapy in older patients, physicians should have and document a discussion with patients and caregivers about the risks and benefits of these medications.C2, 13, 14
The use of atypical antipsychotics for behavioral and psychological symptoms of dementia is associated with increased mortality.A23, 24
Antipsychotic medications should be discontinued if there is no evidence of symptom improvement.A13, 29, 30

Symptoms of Dementia

Approximately 15% to 75% of persons with dementia have delusions, delusional misidentifications, hallucinations (usually visual), wandering, agitation, aggression, and other psychotic behaviors.6 Collectively, these symptoms are referred to as behavioral and psychological symptoms of dementia. These symptoms contribute to caregiver fatigue and burnout, which often influence the decision to seek out-of-home care. These symptoms are often indicative of underlying emotional distress, pain, delirium, or physical discomforts, which can be treated supportively. Family and caregivers benefit from education about current and anticipated dementia symptoms and reminders that the behaviors are normal and unintentional.

Nonpharmacologic Management

The American Geriatrics Society and American Association for Geriatric Psychiatry consider nonpharmacologic interventions first-line treatment for behavioral and psychological symptoms of dementia.7 Physicians should assess for potential underlying causes of the concerning behaviors. Clinicians and caregivers should evaluate and treat physical discomforts such as thirst, hunger, pain, toileting difficulties, or nausea.8 Sleep deprivation, fatigue, depression, loneliness, boredom, overstimulation, and social stressors may serve as emotional triggers.7 Physical and emotional symptoms can be treated by establishing routines for toileting, eating, medication administration, sleep, and socialization. If routines do not correct the behaviors and safety concerns remain, physical barriers to wandering may be necessary.

Behaviors that are not corrected with environmental measures may respond to more extensive interventions7 (Table 1711 ). The strength of supporting evidence for these interventions varies, but in general, they have been associated with no more than modest benefits.

Assess for physical discomfortsEnsure that physical needs are being met (thirst, hunger, pain, toileting, nausea, sleep)May eliminate secondary source of symptomsLimited effectiveness in advanced disease
Establish routinesEnsure routine in socialization and activities of daily living (toileting, eating, medication administration, sleep)May improve general behaviorLimited effectiveness in advanced disease
Cognitive and emotion-oriented interventionsCognitive stimulation (e.g., task-oriented behaviors for distraction)Improves quality of life, communication, and interactionLimited effectiveness in advanced disease
Reminiscence therapyImproves cognition and moodNot directly associated with decreased symptoms
Simulated presence therapy (audio or video recordings)Helpful for verbally disruptive behaviorMay require technical equipment
Validation therapy (acknowledgment, redirection)May improve general behaviorInconclusive evidence
Sensory stimulationAcupunctureUnclear benefitsRequires technical expertise; varied protocols
AromatherapyMay decrease agitationRequires equipment; mixed evidence
Light therapyImproves sleep and daytime behaviors; inexpensiveNonstandardized
Massage/touchDecreases wanderingMay require technical expertise
Music therapyMay decrease agitationLimited effectiveness in patients with hearing impairment
Behavior managementReinforcement techniques (e.g., extinction, differential reinforcement)Modest reduction in problematic behaviorsRequires consistency and caregiver education
Other psychosocial interventionsAnimal-assisted therapyDecreases anxiety and increases apparent joyMay require infection control; nonstandardized
ExerciseMay decrease depressive symptomsRequires physical ability

Cognitive and emotion-oriented interventions include cognitive stimulation, reminiscence therapy, simulated presence therapy, and validation therapy. Cognitive stimulation includes regularly scheduled mentally stimulating activities.10 During reminiscence therapy, the patient engages with another person or group in remembering past activities, events, or experiences.9 In simulated presence therapy, audio or audiovisual recordings are played to mimic the presence of a loved one. Validation therapy involves acknowledging the patient's current emotional state or voiced wishes and may include redirection from the unwanted behavior.

Sensory stimulation interventions include acupuncture, aromatherapy, light therapy, massage, and music therapy. Behavior management techniques include extinction and differential reinforcement. Extinction is withholding of positive reinforcement during inappropriate behavior. Differential reinforcement rewards quiet behavior or actions that are incompatible with the inappropriate behavior. Reinforcements can include social reinforcement, touch, food, and pleasurable activities.12 Other psychosocial interventions include animal-assisted therapy and exercise.10

Appropriate Antipsychotic Use and Safety


Antipsychotics are often used to treat refractory or severe behavioral and psychological symptoms of dementia, although the FDA has not approved this use because of low-quality evidence of benefit and good-quality evidence of harm.1,2 If first-line, nonpharmacologic therapies are ineffective, physicians should consider the risks and benefits of initiating off-label antipsychotic medications. Clinicians should initiate treatment only if the behaviors pose a risk of harm to the patient or others (e.g., hitting, verbal assaults, dangerous wandering) or if they are severely debilitating and other resources have been exhausted.13 Medication should be started at the lowest dose and titrated slowly.4 The risks, benefits, therapeutic goals, and adverse effects should be discussed with the patient and caregivers before therapy is initiated and again at every encounter.2,14 Written documentation of counseling sessions is essential for continuing assessment of treatment goals. Physicians may consider administering antipsychotics at bedtime to take advantage of their sedating effect.


Three meta-analyses of atypical antipsychotics showed that aripiprazole (Abilify) use consistently resulted in small average reductions in behavioral and psychological symptoms of dementia.1517 Symptom improvement was noted with lower dosages (2 to 10 mg per day).

Olanzapine (Zyprexa; 5 mg per day), quetiapine (Seroquel; 50 mg per day), and risperidone (Risperdal; 0.25 to 1.5 mg per day) were inconsistently effective for the treatment of behavioral and psychological symptoms of dementia, with olanzapine and quetiapine having the least effect on symptom scores.15,16 Ineffective antipsychotics include ziprasidone (Geodon), paliperidone (Invega), clozapine (Clozaril), asenapine (Saphris), and iloperidone (Fanapt).15


Antidopaminergic effects (e.g., movement disorders) are more common among first-generation antipsychotics but also occur with atypical antipsychotics (Table 218 and Table 31922 ). Additional adverse effects include anticholinergic effects, extrapyramidal symptoms, neuroleptic malignant syndrome, hyperprolactinemia, postural hypotension, sedation, stroke, and prolonged QT interval. Long-term use of antipsychotics is associated with increased risk of metabolic syndrome, obesity, diabetes mellitus, hypertension, and dyslipidemia.18

Adverse effectAripiprazole (Abilify)HaloperidolOlanzapine (Zyprexa)Quetiapine (Seroquel)Risperidone (Risperdal)Ziprasidone (Geodon)
Anticholinergic effects0+++00
Extrapyramidal symptoms++++0+++
Neuroleptic malignant syndrome++++++
Postural hypotension+++++++++
Prolonged QT interval++++++++
Sexual dysfunction++++++++
Type 2 diabetes mellitus+++++++
Weight gain0++++++++0
Adverse effectClinical signs
Anticholinergic effectsBlurred vision, confusion, constipation, dry mouth, urinary retention
Extrapyramidal symptomsMuscle spasms, pseudoparkinsonism (bradykinesia, rigidity, tremor), restlessness
HyperprolactinemiaAcne, galactorrhea, gynecomastia, hirsutism, reduced bone density
Neuroleptic malignant syndromeAutonomic instability (tachycardia, labile hypertension), hyperthermia, muscle rigidity (lead pipe rigidity), tremor, worsened dementia
Tardive dyskinesiaChorea, irreversible involuntary muscle spasms, myoclonus (usually in the orofacial region), tics

Although general adverse effects are significant, evidence of increased mortality is more concerning. In a 2015 retrospective case-control study of more than 90,000 Veteran's Administration beneficiaries with dementia, patients who received typical or atypical antipsychotics had a greater risk of death than those who did not receive these medications.23 The first-generation antipsychotic haloperidol had a number needed to treat to harm (NNH) of 26 (95% confidence interval [CI], 15 to 99). Of the second-generation antipsychotics studied, quetiapine increased mortality the least (NNH = 50; 95% CI, 30 to 150), followed by olanzapine (NNH = 40; 95% CI, 21 to 312) and risperidone (NNH = 27; 95% CI, 19 to 46). As a group, olanzapine, quetiapine, and risperidone had a 3.5% absolute increase in mortality (95% CI, 0.5% to 6.5%; NNH = 29) at higher vs. lower doses.24 Aripiprazole increases the risk of cardiac and cerebrovascular events (NNH = 58; 95% CI, 20 to 240), but its effect on mortality is not known.15


The American Diabetes Association and American Psychiatric Association have guidelines for the long-term monitoring of patients receiving antipsychotics (Table 4).25,26 Physicians should consider the clinical context and anticipated duration of treatment when ordering these tests and monitoring effects. For example, patients with a life expectancy of less than 10 years may not benefit from monitoring for modifiable cardiovascular risk factors. However, regular assessment of dose-related adverse effects, such as extrapyramidal symptoms and sedation, may lead to dose reduction with acute benefits. Because older patients have decreased renal blood flow resulting in decreased renal clearance, assessment of renal function and subsequent dosing adjustments are key to reducing adverse effects in this population. Collaboration with a clinical pharmacist may help in reducing polypharmacy, monitoring for interactions, and making appropriate dose adjustments.27,28

Adverse effectMonitoring
CataractsSlit lamp examination at treatment initiation and every six months if patient is receiving quetiapine (Seroquel)
Diabetes mellitus or metabolic syndromeLipid panel; check fasting plasma glucose level at treatment initiation, at 12 weeks, then annually if receiving atypical antipsychotics; measure waist circumference and BMI at initiation and when dosage changes, then at every visit for six months; initiate quarterly nutrition counseling if BMI increases by more than 1 kg per m2; check blood pressure at initiation and when dosage changes, then every three months for first year
Extrapyramidal symptomsAssess for symptoms, including tardive dyskinesia and restlessness, at treatment initiation and when dosage changes, then weekly until dose is stable for two weeks, then yearly if receiving an atypical antipsychotic
Prolonged QT intervalBaseline electrocardiography if patient has history of heart disease, syncope, sudden death in a family member younger than 40 years, congenitally prolonged QT interval, or polypharmacy


A 2013 Cochrane review found that in eight of nine trials, there was no significant difference in behavioral and psychological symptoms of dementia after discontinuation of antipsychotics, indicating that the medications were ineffective in treating their target symptoms.29 Therefore, if symptoms do not improve after a four-week trial13 of antipsychotic medications, they should be discontinued.30 There is no evidence that discontinuation of antipsychotics has a negative effect on quality of life, ability to perform daily tasks, or intellectual processes of patients who have not benefited from treatment.

One trial demonstrated relapse of symptoms after medication discontinuation in patients who had successful symptom control, suggesting that some patients do benefit from antipsychotics beyond the short term.31 If patients' symptoms improve, clinicians should use the smallest dose for the shortest possible duration to reduce adverse effects.14

Data Sources: Searches were performed in PubMed, the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Agency for Healthcare Research and Quality, and Essential Evidence. Key search words included antipsychotic, elderly, geriatric, dementia, delirium, geriatric psychiatry, agitation, and behavioral symptoms of dementia. Search dates: July 2015, September 2015, October 2015, January 2016, and April 2016.

The authors thank Diane Kunichika and Mark Ebell for their assistance with literature acquisition, and Muna Cocker for editorial oversight.


This article updates previous articles on this topic by Rayner, et al.,4 and Motsinger, et al.32

The views expressed in the manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the U.S. government.

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