Dementia and psychotropic medicines

Understanding the options available to manage changed behaviour in this complex condition

 

For consumers, check out
 Medicines and dementia: what you need to know

Dementia and psychotropic medicines

Key points

  • Non-pharmacological interventions are recommended as first-line management of changed behaviour in dementia, and should be continued even if a medicine is trialled.
  • Health professionals are encouraged to be guided by a person's background, likes and dislikes, culture and life experiences to choose appropriate non-pharmacological interventions.
  • When antipsychotic medicines and benzodiazepines are used, review early and often for the emergence of adverse effects.
  • Antipsychotic medicines should only be used in severe cases of changed behaviour where non-pharmacological interventions have failed.
  • Consider ceasing an antipsychotic medicine if the targeted behaviour has not improved after 1–2 weeks, or if the person has been taking the medicine for at least 12 weeks.

Language

Guidelines use the term ‘behavioural and psychological symptoms of dementia' (BPSD), but peak bodies such as Dementia Australia prefer terms such as 'expressions of unmet need' or 'changed behaviours'. We have adopted similar language in our newer resources to support these groups in moving towards a more person-centred terminology.

 
 

Medicinewise News: A portrait of dementia and changed behaviours

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Changed behaviours in people with dementia present unique challenges for the individual, their family and carers, GPs and other health professionals.

Dr Troye Wallett, a GP with a specific interest in working with older Australians, has provided a real-life example to highlight some critical issues in caring for a person with dementia experiencing changed behaviours.

Read the full article 

 

Dementia and changed behaviours: supporting the person at the centre

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Person-centred care for people with changed behaviours relies on comprehensive assessment and a multidisciplinary approach that includes the person and their carers. 

Read the full article

 

Health professionals’ guide to person-centred dementia care

Older man painting while nurse looks on

We have collected external guidelines and resources that may help health professionals in caring for people with dementia experiencing changed behaviours. 

These cover topics including identifying and understanding why changed behaviours present, person-centred approaches to help with these behaviours, safe prescribing and deprescribing of antipsychotics, and information about consent and rights of the individual, their family and carers.

Find the resources

 

Reviewing and tapering antipsychotic medicines for changed behaviour

A tool to facilitate multidisciplinary review of antipsychotic medicines prescribed for patients experiencing changed behaviour, including advice on how and when to taper.

 

Australian Prescriber articles

Managing behavioural and psychological symptoms in dementia

Stephen Macfarlane, Daniel O’Connor 
Aust Prescr 2016;39:123–5

Behavioural and psychological symptoms should be managed without drugs whenever possible. Although there is little evidence to support their use, antipsychotic drugs are often prescribed to people with dementia.

Read the full article

Combination psychotropic medicine use in older adults and risk of hip fracture

Kerrie Westaway, Natalie Blacker, Russell Shute, Rosemary Allin, Zain Elgebaly, Oliver Frank, Nicole Pratt, Elizabeth Roughead 
Aust Prescr 2019;42:93–6

Falls typically result from multiple interacting factors. The more factors present, the more likely the person is to fall.

Read the full article

Stopping and switching antipsychotic drugs

Nicholas Keks, Darren Schwartz, Judy Hope 
Aust Prescr 2019;42:152–7

While antipsychotics are often needed long term, there are circumstances when clinicians, patients and families should reconsider the benefits versus the harms of continuing treatment. Care is needed to avoid psychosis during the changeover.

Read the full article

 

Choosing Wisely Australia

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Choosing Wisely Australia is an initiative that brings the community together to improve the quality of healthcare through considering tests, treatments and procedures where evidence shows they provide no benefit or, in some cases, lead to harm.

Led by Australia’s colleges, societies and associations and facilitated by NPS MedicineWise, Choosing Wisely Australia challenges the way we think about healthcare, questioning the notion 'more is always better'

Recommendations from Australian and New Zealand Society for Geriatric Medicine

Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.

Do not prescribe benzodiazepines or other sedative-hypnotics to older adults as first choice for insomnia, agitation or delirium.

    Recommendation from The Society of Hospital Pharmacists of Australia

    Do not initiate and continue antipsychotic medicines for behavioural and psychological symptoms of dementia for more than 3 months.

      Recommendation from Pharmaceutical Society of Australia

      Do not continue benzodiazepines, other sedative hypnotics or antipsychotics in older adults for insomnia, agitation or delirium for more than 3 months without review.

      For your patients

      This planner can help patients or their carers track behaviour over time, to help the care team personalise dementia care.

       

      Clinical resources and tools

      Reviewing and tapering antipsychotic medicines for changed behaviour

      A tool to facilitate multidisciplinary review of antipsychotic medicines prescribed for patients experiencing changed behaviour, including advice on how and when to taper.

      Implementing non-pharmacological interventions for changed behaviour

      A resource for health professionals and care staff that provides non-pharmacological strategies suitable for implementation in an aged care setting.

      Stepwise approach to changed behaviour

      A resource for health professionals and care staff that demonstrates a stepwise approach to managing changed behaviour.

      Stepwise approach to changed behaviour

      Date published : 29 October 2020

       

      Dementia Training Australia:  Responsive Behaviours Quick Reference Cards

      Available on the Dementia Training Australia website, these cards are a resource for health professionals and care staff working with people with dementia to help guide the management of changed behaviours. 

      Download the cards

      The Dementia Centre for Research Collaboration: Dementia Outcomes Measurement Suite

      A compendium of validated tools to help health care professionals assess various aspects of dementia.

      View the suite

      Research summary

      Authors

      Reference

      Summary

      Dementia Collaborative Research Centre, 2012

      Behaviour management a guide to good practice – Managing behavioural and psychological symptoms of dementia

      This guide supports health professionals and care staff caring for people living with dementia, who present with changed behaviour. A comprehensive evidence and practice-based overview of management principles is provided, with practical strategies and interventions.

      Royal Australian and New Zealand College of Psychiatrists, 2016

      Professional Practice Guideline 10: Antipsychotic medications as treatment for behavioural and psychological symptoms of dementia

      These guidelines provide health professionals with recommendations reflecting current evidence on antipsychotic medicine use for patients with changed behaviour.

      Guideline Adaptation Committee, 2016

      Clinical practice guidelines and principles of care for people with dementia

      These guidelines provide health professionals and carers in primary care, aged care and hospital settings with access to recommendations reflecting current evidence on dementia care to better respond to the needs and preferences of the person living with dementia.

      Westbury et al, 2017

      Reducing the use of sedative medication in aged care facilities: Implementation of the ‘RedUSe’ project into everyday practice

      RedUSe is a University of Tasmania national project that promotes the appropriate use of sedatives, in particular antipsychotics and benzodiazepines, in residential aged care facilities (RACFs) in Australia.

      RedUSe is a multi-strategic, interdisciplinary and structured initiative that has proven an effective intervention to significantly reduce RACF antipsychotic and benzodiazepine use, with high degrees of staff, pharmacist and GP satisfaction.

      Find out more about RedUSe