The Dangers of Using Antipsychotics for Dementia

Alzheimer's disease affects almost 6 million people in the U.S., and it’s the leading cause of dementia. But a person with Alzheimer's disease may not only have trouble remembering things or performing daily activities — they may also start experiencing mental health symptoms.

People with Alzheimer's disease have a higher risk of developing depression or agitation. They may also become aggressive or experience hallucinations (seeing or hearing things that aren’t there). These symptoms can be referred to as dementia-related psychosis. And they can be difficult to treat.

For years, many people with Alzheimer's disease were prescribed antipsychotic medications to help manage these symptoms. But because of serious risks, that’s no longer the case.

Why are antipsychotics not recommended in dementia?

Simply put, antipsychotics may raise the risk of death for people with dementia-related psychosis. They also increase the risk of other health problems, like worsening dementia symptoms, falls, and blood clots.

Antipsychotics were never FDA approved to treat people with dementia. But because they can help with agitation, they were used off-label in older adults living with dementia. For example, a 2007 study found that about 32% of nursing home residents were prescribed an antipsychotic. Many of these people didn’t have mental health conditions, such as schizophrenia, that are typically treated with these medications.

There was a growing concern about this use of antipsychotics. Research in the early 2000s started finding a higher risk of stroke in people with dementia being treated with antipsychotics. But other studies also noted a higher risk of death from any cause with these medications.

These risks are most prominent with atypical antipsychotics like risperidone (Risperdal). But they’ve also been reported with typical antipsychotics like haloperidol. These findings led the FDA to place a boxed warning (the strictest warning for medications) on all antipsychotics. The boxed warning details the risks and notes that antipsychotics aren’t approved for dementia-related psychosis.

Why do antipsychotics cause death in people with dementia?

Experts aren’t sure why antipsychotics raise the risk of death. They just know that these medications do cause the risk to go up. Most available research uses data that’s collected after events occurred. This type of research makes it hard to identify why antipsychotics raise the risk of death.

Some experts believe that antipsychotics raise the risk of death for all older adults, not just those with dementia. They’ve also noted that older adults — with and without dementia — are more likely to have other health conditions, like heart disease or diabetes. These conditions can be worsened by antipsychotics.

So there could be multiple factors at play. But like a domino rally, there can be one piece that causes everything else to fall. And in this case, antipsychotics seem like they may be that initial push.

Should a healthcare provider ever use antipsychotics for dementia?

Antipsychotics can be prescribed for people with dementia in very specific situations. But they’re typically avoided.

In 2016, the American Psychiatric Association (APA) released guidelines on when and how to use antipsychotics for dementia-related psychosis. The APA recommends that antipsychotics should only be used when a person’s symptoms are severe or dangerous. For example, they may be considered if a person is a harm to themselves or others because of aggressive behavior.

The APA suggests healthcare providers start with low doses of antipsychotics. They also strongly urge providers to closely monitor for side effects.

Which antipsychotics may help dementia and Alzheimer’s symptoms?

The APA doesn’t recommend one antipsychotic over another to help people with dementia. In addition, a review of several studies didn't find one antipsychotic to be better over others in terms of effectiveness or safety.

What is recommended is limiting the use of any antipsychotic. If no benefit is seen after 4 weeks of prescribing it, the antipsychotic should be stopped. Even if benefits are seen, it’s suggested that healthcare providers consider stopping the medication after 4 months. Continuing an antipsychotic is only recommended if a person’s symptoms gets worse while they’re weaning off the medication.

Can antipsychotics cause dementia?

No. The evidence that’s currently available doesn’t suggest antipsychotics cause dementia. People living with schizophrenia seem to have a greater risk for developing dementia than those without the condition. And antipsychotics are a mainstay of schizophrenia treatment. But more research is needed to confirm if there’s any connection between the medications and dementia for this group of people.

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Written by:

Timothy Aungst, PharmD

Timothy Aungst, PharmD, has worked in pharmacy practice for the past decade with different roles and responsibilities. He has served as an associate professor of pharmacy practice for almost a decade, a clinical pharmacist in outpatient cardiology management, and now in home healthcare.

Edited by:

Christina Aungst, PharmD

Christina Aungst, PharmD, is a pharmacy editor for GoodRx. She began writing for GoodRx Health in 2019, transitioning from freelance writer to editor in 2021.

Reviewed by:

Austin Ulrich, PharmD, BCACP

Austin Ulrich, PharmD, BCACP, is a board-certified ambulatory care clinical pharmacist. In his early career, he provided direct patient care in a variety of settings, including hospital and community pharmacies, and in a primary care clinic as a clinical pharmacist.

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