Antipsychotics in dementia: Best Practice Guide

Introduction, Rationale and Key Points   Behavioural and Psychological Symptoms of Dementia (BPSD)   Assessment of patients with BPSD   Non-pharmacological treatment of BPSD   Pharmacological treatment of BPSD   Adverse effects of antipsychotics   Dementia with Lewy Bodies (DLB)   Other medicines for BPSD   Treatment of comorbid conditions in patients with dementia   References   Appendix

Appendix: Best practice prescribing of antipsychotics for elders in residential care (algorithm)

These recommendations represent the expert opinion and evidence-based knowledge of the RANZCP Faculty of Psychiatry of Old Age (New Zealand). Published clinical trial evidence relating to this area of prescribing is sometimes sparse, preliminary or even non-existent in respect of many of the issues covered. Pooled clinical expertise, relevant international guidelines and peer-reviewed research literature have been critical to developing these recommendations. The algorithm below summarises these recommendations.

	Work on developing a shared culture of care that supports best-practice antipsychotic prescribing.
	Identify the target problem. Record intensity, frequency and consequences.
	Set a realistic treatment aim
	Formulate the target problem	Manage any contributing medical or psychiatric conditions
Initiate non-pharmacological management specific general Continue in parallel with any pharmacological treatment.	Decide whether or not to trial an antipsychotic: Is the target problem likely to respond? Is the acuity high enough (in terms of suffering and risk)? Do the likely benefits outweigh the risks? Is non-pharmacological management effective on its own?
	Initiate an antipsychotic trial: Choose an appropriate antipsychotic based on the person’s side effect risk profile Decide on the target dose and length of trial Educate staff on side effects of concern Decide on a monitoring plan
	Gain appropriate consent given the circumstances
	Titrate medicine up to target does for length of treatment trial unless side effects or effectiveness occur earlier
	Formally evaluate the trialled management
Continue the medication and non-pharmacological approaches with regular review and consideration of dose adjustment and cessation     Carefully withdraw treatment and reconsider the problem and its management

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