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Evidence for the efficacy of drugs is limited and the risk of adverse effects is significant (including death with antipsychotics). Behaviours that respond poorly to medication include disruptive vocalisations, shouting, wandering, pacing, repetition, cognitive deficits, incontinence, voiding inappropriately, insomnia and withdrawal.

Psychotropic medicines have a modest effect on dementia related behaviours overall, but medicines that specifically target depression or psychosis have greater efficacy.

Informed consent from the person or their guardian must be obtained prior to medication commencement.

Classes of medicines used in behaviour management include antipsychotics, benzodiazepines, anticholinesterases, N-methyl-D-aspartate (NMDA) antagonist, anticonvulsants and antidepressants.

 

Medication review

  • Monitor closely when starting medication or increasing the dose to ensure the target behaviour improves and that adverse effects are tolerated
  • Review the need for continuing antipsychotic therapy within 3 months and regularly after this. Withdrawing antipsychotic treatment may not worsen behaviour, provided it is done gradually
  • There should be specific monitoring of side effects such as drowsiness, restlessness, limb stiffness, reduced mobility, abnormal involuntary movements (e.g. tremor, abnormal mouth movements) and postural hypotension (dizziness on standing)
  • Involving a medical specialist in prescribing and/or reviewing medications is highly recommended.

Commencing medication

  • Start any new medication at the lowest possible dose
  • Only start one new medication at a time – if there has been no benefit after 2-3 weeks, the dose could be increased gradually
  • Any increase in dose should be small and made slowly
  • Use an antipsychotic only if aggression, agitation or psychotic symptoms cause severe distress or an immediate risk of harm
  • Non-pharmacological interventions should continue to be used in conjunction with any pharmacological therapy.
 

Important considerations

  • Only commence drug treatment for BPSD once physical causes have been addressed and the behaviours have not responded to non-pharmacological strategies.
  • Side-effects and drug interactions need to be considered prior to prescribing
  • It may be necessary to wait several weeks before efficacy can be assessed
  • There should be careful monitoring and documenting of adverse effects and intended benefits

 

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