Guidelines for Antipsychotics in Dementia—Part 2

by, Dr. Al Power, ChangingAging Contributor

In Part 1 of this post, I listed several preliminary comments and concerns regarding the use of these drugs. I continue to maintain that antipsychotics are “the physical restraints of the 21^st century,” meaning that their use should become the rare exception, once we have navigated the same type of learning curve.

But given the reality that most people are not currently equipped with the knowledge and resources to implement other solutions, there will be times when the use of medication may need to be considered. So here are some guidelines for those along the journey who have not yet created the infrastructure for an anti-psychotic-free environment. As I implied in Part 1, these guidelines will be more specific and restrictive than others published to date.

First the Standard Disclaimer: “The following recommendations are my own; they do not reflect current national or state guidelines, nor do they represent the positions of any medical or other professional organizations.” Okay? Here we go, in italics, to give it gravitas…

The use of an antipsychotic medication in a person living with dementia could be considered in the following situations:

1. A person with evidence of an ongoing underlying psychiatric disorder (such as schizophrenia, major depression with psychosis, or bipolar disorder with mania) who needs antipsychotic therapy for that condition.
   Comment: Some psychiatric conditions may stabilize or resolve, in which case long-term use would not be necessary.
2. A person with true, ongoing, and disturbing delusions or hallucinations (usually as a consequence of delirium) that are not easily resolved through adjustment of medications or treatment of underlying illness.
   Comments: Most expressions that are characterized as delusional or hallucinatory are incorrectly labeled and are actually misinterpretations of the environment due to memory loss and changes in one’s perception of verbal and non-verbal communication.
   True delusions are also repetitive and persist over time. Also, note the qualifying term “disturbing,” which means these feelings must be disturbing to the person in question (as opposed to family members or care staff). Expressions that do not cause undue distress for the individual do not need to be medicated.True hallucinations—outside of schizophrenia—are more often visual, and are usually the result of drug toxicity or other acute illness; therefore, attention to the underlying cause is the primary response. (An exception is Lewy body dementia; but the mechanism here is damage to the nerves of the visual cortex. Antipsychotics are largely ineffective for this illness and potentially dangerous. Also, most people with LBD have been given anti-Parkinson drugs for their rigidity—these are the most hallucinogenic drugs we prescribe, and usually of little benefit for this condition—so those drugs should be tapered or stopped as our first response.)
3. A person who presents an imminent and ongoing danger to oneself or others, for whom no readily available means to defuse the situation can be found.
   Comment: If an altercation occurs and our subsequent intervention restores calm, this is not a sufficient reason for an antipsychotic. There must be a reasonably high risk of recurrence of the potentially dangerous situation in the short term to justify starting sedating medication.
4. Severe and persistent anxiety that poses a significant threat to health and well-being, for which other approaches have proven ineffective.
   Comment: Significant threats may include inability to eat or other measurable effects on health. Antipsychotics do not usually help this situation, but may provide some degree of sedation until more effective approaches (such as antidepressants and/or non-drug approaches to well-being) can be optimized. Also, keep in mind that a common cause of restlessness is akathisia—a condition of severe motor restlessness that is a side effect of antipsychotic drugs; this is often misinterpreted as agitation and can result in an increase in the antipsychotic dose, thus producing more harm.
5. The following are not indications for antipsychotic use: calling out, and other repetitive verbalizations, insomnia, attempts to stand, walk, or exit a building, expressions of anger, mild to moderate anxiety, and most cases of striking out during care. Expressions of suspicion do not constitute paranoia that justifies antipsychotic treatment unless they are persistent and delusional, not explainable by environmental, verbal, and nonverbal signals, and significantly interfere with the person’s health.

 The following protocol should be followed whenever antipsychotic drugs are ordered:

1. The person must be examined by a medical professional within 72 hours of any order for antipsychotics (including an increase in dose).
2. A note in the medical record reflecting the appropriate aforementioned criterion should justify the decision to order the drug.
3. Informed consent for the medication must be obtained within 72 hours. The person receiving the medication should be approached first for consent, and if that person is found to lack capacity for such consent, the health care proxy or designated surrogate would need to sign. A diagnosis of dementia or an abnormal cognitive test is not sufficient to presume lack of capacity in this regard.
4. A team meeting must be held (with the medical professional in attendance) within 1 week of the start of the medication to discuss the situation in detail and outline a plan to identify and support unmet needs or minimize other triggers. The team should meet regularly to update progress and amend the plan as needed.
5. All of the aforementioned criteria for drug use (except #1) should be considered indications for short-term antipsychotic use only. A schedule for regular reviews with an attempt to taper the medication should be devised after the initial meeting.
6. Every subsequent medical visit must include a review the use of the medication and must follow current guidelines for evaluation of potential physical, cognitive, or laboratory abnormalities as a result of the drug. Any new abnormality should trigger a consideration of more rapid removal of the drug.
7. If the situation persists after a reasonable period of time while using a stable medication dosage, the antipsychotic drug is considered ineffective and should be stopped. If the person’s initial symptoms were due to underlying drug toxicity or delirium, the antipsychotic drug should be stopped when the underlying condition is under control.
   Comment: I am continually amazed at how often one of these drugs is prescribed, and even though the situation doesn’t improve, the drug is simply continued month after month. There is no other drug that we would continue using in the face of a lack of benefit (except for other drugs used for Alzheimer’s!).

Keep in mind that these criteria should be adapted to all living environments; remember that the inappropriate use of antipsychotic drugs is much higher in the community than it is in nursing homes!

I will expand upon my comments about hallucinations and delusions in a future post.

I hope that as the learning curve progresses and we make further progress in eliminating these drugs, these criteria could be tightened up even further. This is my first shot at writing such recommendations. Feel free to share your feedback. I may or may not amend them as time goes on.