Nearly four in ten Australian aged care residents are prescribed an antipsychotic, despite the fact they often don’t work, have serious adverse effects, and are only recommended for managing dementia-related behaviours when other strategies have failed.

Getting to the root of these behaviours is key to managing them effectively—without necessarily needing to prescribe any medications at all.

Screen for underlying causes

Over 90% of people with dementia will exhibit responsive behaviours such as agitation, wandering, and hallucinations at some point, but these behaviours are not intrinsic to the condition, says geriatrician Associate Professor Michael Woodward AM, Dementia Australia Honorary Advisor and Director of the Aged Care Research and Memory Clinic, Austin Health.

Both international and national clinical guidelines recommend looking for environmental, psychosocial and physical health factors that may be contributing to behavioural symptoms as a first line.

It’s important to exclude medical causes that may underlie these behaviours, says consultant psychiatrist Steve Macfarlane, Associate Professor of Aged Psychiatry at Monash University and Head of Clinical Services for Dementia Support Australia.

Common examples include pain, constipation, delirium, infection, or poorly controlled diabetes.

Associate Professor Woodward says while blood tests usually yield more information about causes of delirium than of behavioural change, they are still worth doing. He suggests running a U&E and full blood count and possibly checking haemoglobin, CRPs, calcium, B12, folate, and liver and thyroid function if these have not been done in the past year.

Consider the person’s background and circumstances

The person’s life experience and environment may also help explain their behaviours.

“It’s good to try and work out what the precipitant is and get an idea what the person was like in the past,” Associate Professor Woodward says.

“It might be that a male is agitated when they’re being bathed by a female care attendant. It could be that they’ve previously been an usher in a theatre and they like to line the chairs up, which annoys everybody.”

“Sometimes changes can then be made to the environment rather than immediately reaching for the prescription pad.”

This type of information can be gleaned from the person’s family, care staff, or the aged care assessment team, he says.

Support for non-pharmacological strategies

However, this can be a time-consuming task that is not feasible for GPs, Associate Professor Macfarlane says.

Dementia Support Australia has a free nationwide service with consultants who can get to patients within a week and within 48 hour for severe cases—with telehealth support available in the interim.

Their allied health professionals and nurses spend up to a day in a facility to determine what is contributing to a behavioural symptom, then “provide non-pharmacological management strategies that target the cause rather than just the symptom itself,” Associate Professor Macfarlane says.

For example, they were asked to see one man because of his “daily unprovoked acts of aggression towards visitors and staff,” Associate Professor Macfarlane says. They learned he was a retired union organiser with a deep distrust of management, and was targeting staff who carried clipboards––which he interpreted as management snooping––and men wearing white shirts, whom he perceived as “management types.”

“Once staff were advised not to wander the floor with clipboards and warned against wearing white shirts, his behaviour settled, and we got him off his antipsychotics. But unless you knew his background, you’d have no prima facie knowledge of whether those interventions were going to be valid or not,” he says.

A two-year retrospective study found Dementia Support Australia’s interventions led to statistically and clinically significant improvements in behavioural symptoms and the distress they cause to caregivers.

Referral for a comprehensive geriatric assessment may be appropriate in some cases, Professor Woodward adds.

Prescribe judiciously

Many aged care residents are on medications to manage behaviour, but drugs often don’t work and have a range of problematic side effects, Associate Professor Macfarlane says.

“Non-pharma approaches are universally recommended as being first line, and they are more effective, according to the evidence that we have, than drug-based approaches.”

It can be worth trialling pain relief before prescribing anything else, he says.

“From the Dementia Support Australia experience, the most common contributing factor to behaviour we come across is unrecognised or undertreated pain. So just a trial of simple analgesia, if you’re going to use any pharmacotherapy, is probably the simplest and the path of least harm.”

Depression is also worth considering but can be difficult to recognise, he adds, noting diagnosis depends on the ability to report your symptoms, and there is not a validated tool or agreement about which symptoms constitute an episode of depression in somebody with severe dementia.

Nonetheless, “if you look at expert consensus guidelines, a trial of an antidepressant is above antipsychotics in terms of the management algorithm,” he says.

“And it’s not because antidepressants have a magical effect on behaviour and dementia. It’s probably because a proportion of what we label as behaviour in dementia is in fact unrecognised depression.”

Avoid antipsychotics if possible

While international consensus guidelines list risperidone as the last of eight strategies for treating dementia-related behaviours other than psychosis, 40% of aged care residents in Australia are prescribed an antipsychotic, Associate Professor Macfarlane says.

A 2017 review of 15 systematic reviews examining 18 pharmacological and non-pharmacological interventions for managing behavioural symptoms of dementia concluded that while atypical antipsychotics have a statistically significant but small effect, they “should be avoided where possible due to the high risk of serious adverse events and availability of safer alternatives.”

Antipsychotics may not even be warranted to manage delusions because these are often not caused by psychosis, Associate Professor Macfarlane adds.

“If people have failing memory, for example, and their family visits every day, they might not remember the visit 20 minutes afterwards and swear blind their family never visits them. It’s a fixed false belief that you can’t convince the person out of, so it meets the definition of a delusion, but it’s clearly not mediated by psychosis. You don’t see that sort of belief in other psychotic illnesses like schizophrenia.”

If antipsychotics are deemed necessary, Associate Professor Woodward recommends using the lowest dose for the shortest time possible.

“If you’re going to start risperidone, which is about the only drug for which there is evidence for agitation, psychosis and aggressive behaviour, start with 0.25 milligrams and then rise up to no more than four milligrams a day. That’s the absolute maximum dose. Try and use it for less than 12 weeks—which is all that you’re meant to use it on the PBS—and always try to de-prescribe or back-titrate the dose.”

Further information and resources

Dementia Support Australia has a free advisory service for GPs. Email them with a clinical scenario and one of their geriatricians or old-age psychiatrists will get back to you with advice, usually within one business day. Alternatively, you can arrange a time for a call.

Dementia Support Australia | Behaviour Management – A Guide to Good Practice

Both doctors and patients can call Dementia Australia’s National Dementia Helpline for information and support – 1800 100 500