4.11.1 Management of Behavioural and Psychological Symptoms of Dementia (BPSD)

Alzheimer’s Disease

ChoiceDrugDosage
1st choiceNon-drug treatment / watchful waiting
2nd choice Risperidone 500micrograms, 1mg tablets; liquid 1mg/1mlDose:
Initially 250micrograms once [unlicensed] or twice daily, increased according to response in steps of 250micrograms twice daily on alternate days; usual dose 500micrograms twice daily (up to 1mg twice daily has been required)
Note: Some patients will respond to 250micrograms once daily (lower risk of side-effects) [unlicensed]

Prescribing Notes

  • See PrescQIPP Toolkit on reducing antipsychotic prescribing in dementia and the Dementia Toolkit , NHS England.
  • A high proportion of people with dementia who have behavioural and psychological symptoms (BPSD) experience significant improvements over four weeks with no specific treatment. Watchful waiting (or ‘active monitoring’) is the safest and most effective therapeutic approach unless there is severe risk or extreme distress.
  • If not already receiving treatment, an AChE inhibitor or memantine at maximum tolerated doses should be considered if a non-pharmacological approach is inappropriate or has been ineffective.
  • Refer to community memory team if antipsychotics are being considered.
  • Consider a time-limited trial (6 weeks maximum) of antipsychotics only if specific interventions have been unsuccessful and symptoms are causing extreme distress or risk of harm.
  • Risks of antipsychotics in dementia should be discussed with the patient/carer and the following should be highlighted:
    • a 3 to 4 fold increased risk of cardiovascular event
    • an increased risk of falls
    • an increased risk of diabetes
    • an increased risk of pneumonia
    • an increased rate of decline in dementia
  • If considering an antipsychotic for BPSD, start with a low dose, titrate slowly and monitor regularly, e.g. to assess changes in target symptoms. Allow sufficient time for each dose titration to take effect – many patients will respond to risperidone 250micrograms daily, 250micrograms twice daily or 500micrograms daily if given time. Review at 6 and/or 12 weeks with a view to discontinuation. Discontinuation should be default except in extreme circumstances. Consider referral to a specialist if symptoms persist.
  • Antipsychotics should not be used in Lewy Body Dementia (DLB) without specialist advice.
  • If there is an atypical response to antipsychotics review the initial diagnosis. If there is a Parkinsonian response review and consider cause of dementia e.g. DLB v Alzheimer’s Disease.
  • Risperidone is licensed for: short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer’s dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others. Most antipsychotics are not licensed to manage BPSD.
  • Quetiapine [unlicensed] has not been shown to be as effective as risperidone for BPSD but may be trialled in patients with Parkinson’s disease or DLB (at very low doses) because of its lower risk of causing movement disorders.
  • When stopping an antipsychotic in patients with BPSD:
    • If the person is receiving low dose, proceed directly with discontinuation. Monitor patient and review at two weeks.
    • If the person is receiving a higher dose, taper the dose over one month – reduce to half dose for 2 weeks, review at 2 weeks, discontinue after a further 2 weeks.
  • Refer to the Alzheimer’s Society website for information on non-drug treatment and further advice on managing people with BPSD.

Cautions

  • In the elderly, antipsychotics should be used with caution because of the side-effect profile including extrapyramidal symptoms, sedation, anticholinergic effects, cardiovascular effects and tardive dyskinesia.
  • There is a clear increased risk of stroke and a small increased risk of death when antipsychotics (atypical and typical) are used in elderly people.