Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.
People with dementia may exhibit aggression, resistance to care and other challenging or disruptive behaviours. In such instances, the modest effectiveness of atypical antipsychotics may be offset by the higher risks for adverse events and mortality. Non-pharmacological interventions can be an effective substitute for antipsychotic medications. Use of these drugs should therefore be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others.
- Ballard CG, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev 2006;(1):CD003476.
- Declerq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev 2013;(3):CD007726.
- Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. J Alzheimers Dis 2014;42(3):915-37.
- Richter T, Meyer G, Mohler R, Kopke S. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev 2012;(12):CD008634.
- Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. New England Journal Med 2006;355(15):1525-38.
Members of the Australian & New Zealand Society for Geriatric Medicine completed an online survey asking them to choose the 5 most relevant ‘low value’ practices from a list of 11. Respondents were also asked to nominate any additional practices which they regarded as overused, inappropriate or of limited effectiveness in the specialty of geriatric medicine. A total of 196 responses were received.
The list of items were then subject to consideration by the Federal Council. Specifically, members of Federal Council were asked to rate each of these 16 items in terms of their strength in meeting 7 criteria: Is there a reasonable evidence base upon which to drive change? Are older people likely to benefit from work we might do to change practice? Is the problem sizeable? Are there opportunities and a willingness within geriatric medicine to lead practice change? Are there opportunities to collaborate with other organisations with a shared interest in the area? Will this promote a positive profile for ANZSGM? Is this an area of potential conflict with other Societies?
Based on the ratings they assigned to these items the ‘Top 5’ list items were chosen and reformulated as recommendations for clinicians.
- 1 Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.
- 2 Do not prescribe benzodiazepines or other sedative-hypnotics to older adults as first choice for insomnia, agitation or delirium.
- 3 Do not use antimicrobials to treat bacteriuria in older adults where specific urinary tract symptoms are not present.
- 4 Do not prescribe medication without conducting a drug regimen review.
- 5 Do not use physical restraints to manage behavioural symptoms of hospitalized older adults with delirium except as a last resort.