NHS North Essex

Guidance for the use of

Antipsychotics for people with dementia
Contents
Section Subject Page
1 Introduction 1
2 Reasons for avoiding or reducing the use of antipsychotics 2
3 Alternative non-drug strategies and therapies 2
4 Indications for prescribing 2
5 Assessment of the patient with dementia before considering
antipsychotic medication
3
Rationalising other medicines 3
! "hoice of antipsychotic# and other drugs that have been tried for
behavioural and psychological symptoms of dementia $%&'()
4
* &rescribing A In secondary care settings $acute)
% +or ,-&+. inpatients
" +or ,-&+. outpatients
( +or primary care

!
*
*
/ Reducing and discontinuing antipsychotics and
ben0odia0epines
/
11 &ractical points about discontinuation and planned dose
changes
/
11 .raining and support 11
12 Audit 11
13 References# lin2s and further reading 11
Appendi3 1 4anaging behaviour problems in patients with dementia 12
Appendi3 2 &rescribing guidelines for managing behaviour in patients with
dementia
13
Appendi3 3 'ample 5& letter for discharge from ,-&+. caseload 15
Appendi3 4 4anaging &.'( 6 24-hour sleep and activity chart 1
Appendi3 5 +low chart for memory clinics 1!
! "ntroduction
.he development of behavioural and psychological difficulties or %&'( $for
e3ample agitation# aggression# wandering# shouting# repeated 7uestioning and
sleep disturbance) is common in dementia8 Antipsychotics are widely used to
treat behavioural and psychological symptoms in dementia rather than 9ust for
psychosis8 .hey are often a first-line treatment above non-pharmacological
approaches despite the adverse effects they may produce8 .his guidance is
intended to provide support for ,orth -sse3 to implement the national guidance
Antipsychotic prescribing for people with dementia 121111 &age 1 of 1*
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NHS North Essex
for the safe reduction in the prescribing of antipsychotics and other medicines
for people with dementia8
#! $easons for a%oiding or reducing the use of antipsychotics
It is estimated that of the !11#111 people with dementia in the ;< 1*1#111 were
prescribed antipsychotics8 1#*11 deaths and 1#21 cerebrovascular adverse
events per year were attributable to antipsychotics when the %aner9ee report
was written in 211/8 =ther adverse effects include sedation# increased ris2 of
falls# poorer cognitive function# reduced ability to carry out activities of daily
living $A(>)# blurred vision and constipation# reduced peripheral circulation8
.he national target is to reduce antipsychotic prescribing to 1?3
rd
of its 211/
level before 4arch 21128
&! Alternati%e non'drug strategies
.hese are covered in other papers8 .hey include e3ercise# good regular diet#
occupational therapy# social contact# music# calming environment# cognitive
stimulation# aromatherapy# singing# dancing# massage# sleep hygiene#
distraction techni7ues# providing a feeling of safety# treatment of illnesses
2nown to contribute to dementia or delirium# avoidance of medicines 2nown to
contribute to dementia8

(! "ndications for prescribing
481 Antipsychotics should only be prescribed when@
i) the behavioural symptoms are due to mania or psychosis $see
appendi3 5 for diagnostic codes)
ii) other causes of behavioural and psychological symptoms in dementia
$%&'() have been investigated and treated $e8g8 pain# delirium) but the
patient still has %&'(
iii) non-drug strategies and therapies have been tried and have not been
effective
ii) .he symptoms present a danger to themselves or others8 If so# a
review date must be set at the time of prescribing# and a plan for
reduction or stopping the antipsychotic should be made8
4828 Antipsychotics should only be prescribed with caution by a specialist
for people with >ewy %ody (ementia
4838 Antipsychotics should not be prescribed
i) to routinely sedate the patient for ease of management
Antipsychotic prescribing for people with dementia 121111 &age 2 of 1*
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NHS North Essex
ii) because they were prescribed more than 3 months ago and have not
been reviewed since8
iii) because they were prescribed by secondary care and the symptoms
or circumstances in which they were prescribed no longer apply
)! Assessment of the patient with dementia before considering
antipsychotic medication
5818 ;seful assessment tools may be found in the Al0heimerAs 'ociety paper
B=ptimising treatment and care for people with behavioural and psychological
symptoms of dementiaC :uly 2111 www8al0heimers8org8u2?bpsdguide
582 .he assessment should be within a multidisciplinary team# with a ris2
assessment and a care plan8
5838 "onsideration must be given to
.he patientAs age
.he type of dementia $diagnostic assessment)
"o-morbid psychiatric conditions
&re-e3isting physical health problems
"urrent medication 6 review and rationalise
(rug and alcohol use
'ocial circumstances
"urrent physical and mental health state
"apacity to give consent to treatment
5848 .here must be a discussion with the patientAs family or carers# and their
preferences should be considered8 .he results must be documented8
5858 Relevant investigations should be underta2en to e3clude medical causes
for %&'( $e8g8 blood and urine chec2s# -"5# brain scan)
*! $ationalising other medicines
6.1 (rugs with anticholinergic activity8 .hese can impair cognitive function in
young healthy people# but more so for people with al0heimerAs who
already have low acetylcholine activity which causes the symptoms of
their illness8 -3amples include@
.ricyclic antidepressants $amitriptyline# clomipramine# dosulepin)8
An ''RI antidepressant is a safer option $for e3ample "italopram#
'ertraline)
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Antipsychotics# especially the older ones such as "hlorproma0ine#
>evomeproma0ine# +luphena0ine and depot in9ections8
Anti-histamines $for e3ample "hlorphenamine# &rometha0ine)
Anti-par2insonian drugs such as procyclidine# orphenadrine#
trihe3yphenidyl8
Antispasmodic drugs $for e3ample o3ybutynin# alverine# hyoscine)
(rugs used to treat urinary retention?prostatic hyperplasia
%en0odia0epines# especially short-acting ones8 >ong-acting ones
are more li2ely to cause falls and sedation8
.heophylline# digo3in# furosemide
=piate analgesics especially codeine
If possible these drugs should be gradually reduced and stopped# and a
safer alternative used if necessary8 .hey will counteract the effects of the
cholinesterase inhibitors8
828 Antihypertensives
%lood pressure decreases as the dementia progresses# so the need for
continuing treatment should be reassessed regularly and reduced or
discontinued if no longer needed8 (rugs causing postural hypotension
will increase the ris2 of di00iness and falls8 .he ris2 of treating
hypertension may outweigh the benefits# so increased monitoring and the
use of the lowest possible dose should be considered8
www8nice8org8u2?cg12! August 2111
838 &lease refer to the regional document BRational discontinuation of
medicinesC
Rational
discontinuation of me...
and the 5&-5& algorithm
GP-GP algorithm
Improving drug...
derived from 5arfin2el et al8
+! Choice of antipsychotic for ,PS-
-rug -ose range Comment
Risperidone 251 microgram
6 1mg up to
twice a day
(rug of choice because it is licensed for use for people with
dementia for wee2s8 It has fewer side effects than the older
phenothia0ines or butyrophenones8 It does have significant
anticholinergic effects at higher doses and should not be used
for people with par2insonAs or >ewy body dementia8 It affects
blood sugars $caution with diabetes) and raised prolactin
Antipsychotic prescribing for people with dementia 121111 &age 4 of 1*
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levels may cause osteoporosis8
=lan0apine 285-5mg daily
in one or two
doses
;nlicensed use8 >ess anticholinergic side effects# but may
cause weight gain and blood sugar dyscrasias8 'edative8 In
older adults select a lower initial dose and gradual dose
increase especially if female and?or a non-smo2er8
Duetiapine 1285-111mg
daily in one or
two doses
;nlicensed use8 >ess anticholinergic side effects8 4ay be
used cautiously with par2insonAs or >ewy body dementia8 >ess
effect on weight# blood sugars and prolactin levels8
Aripipra0ole 285-11mg daily
in the morning
;nlicensed use8 As for Duetiapine but less li2ely to cause
drowsiness8 ,egligible effect on the D. interval# use a lower
initial dose in older adults8 4ay cause agitation in first 2
wee2s8
Ealoperidol 251 microgram
6 1mg up to %(
;nlicensed use8 "hec2 -"5 before using8 Anticholinergic side
effects $a2athisia and stiffness)8 (o not use if patient has
par2insonAs disease or lewy body dementia8
>evomepro
ma0ine
1285-111mg ;nlicensed use8 Ris2 of postural hypotensionF not
recommended for ambulant patients over 51 years unless ris2
of hypotensive reaction assessed8 Eigh ris2 of -&'- and
anticholinergic side effects8 4ay have application in palliative
care
Anticholinergic drugs impair cognitive function8 .he anticholinergic burden
$A"%) scale is a useful clinical assessment tool to identify ris2
http@??www8uea8ac8u2?mac?com?media?press?2111?9une?anticholinergicsGstudyGdrugGlist
.ther drugs that ha%e been tried for ,PS-
-rug -ose range Comment
&rometha0ine 11-25mg up to
twice a day
;nlicensed use8 'edating antihistamines have
significant antimuscarinic activity and they should
therefore be used with caution in prostatic hypertrophy#
urinary retention# susceptibility to angle-closure
glaucoma# and pyloroduodenal obstruction8 "aution
may be re7uired in epilepsy8 .he elderly are more
susceptible to side-effects8
.ra0odone 51-151mg
daily
.his is a sedating tricyclic antidepressant with
an3iolytic properties8 "ardiac and antimuscarinic side
effects should be monitored8
4irta0epine 15-45mg at
night
.he lower dose is more sedating because of histamine
bloc2ade8 At higher doses the sedative effect is
reduced because of serotonin receptor stimulation8
Acetylcholinesterase
inhibitors
4ay be a useful alternative for patients with
al0heimerAs disease8 4ust be initiated by specialist
care $see ,orth -sse3 guideline B"ontinuing care
guidance for the use of "holinesterase inhibitors and
4emantineC)
;nlicensed use may be considered for >ewy body
Antipsychotic prescribing for people with dementia 121111 &age 5 of 1*
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dementia or par2insonAs disease
4emantine 5-21mg daily 'ee above8 ;nlicensed use may be considered for
agitation or an3iety
%en0odia0epines (ia0epam 2-
5mg up to .('
Increase the ris2 of falls and may cause rebound
aggression8 4ay be useful for short-term use with
wee2ly review and a plan to taper# stop or start
alternative treatments8 (ia0epam or clona0epam have
a longer half-life8 =3a0epam may be useful if the
patient has low hepatic function8 'hort-acting ones
such as >ora0epam have highest potential for addiction
and withdrawal effects8
/! Prescribing
'ee table appendi3 2
'ee section / for rational reduction of medicines
A0 in a secondary care setting 1acute0
*A818 &atients are not admitted to a secondary care setting unless it is
essential8 .hey may also have spent some time in AH- before being
admitted to an acute hospital ward# so are li2ely to be disoriented#
dehydrated and hungry# possibly having missed essential medication and
having an illness which is causing their %&'(8 4edicines should not be
prescribed until or unless their basic needs are met first and non-drug
strategies have been tried where possible8 .he care pathway for delirium
should be considered
(elirium pathway
Delirium pathway
fowchart Sep...
(elirium patient leaflet
Delirium Leafet
!P"# $!%# "i...
*A828 If an antipsychotic is needed on or shortly after admission# Risperidone
511mcg- 2mg would be first choice# or Ealoperidol 511mcg if the patient
has had a recent -"58 If the patient is unable to swallow tablets
=lan0apine velotab 5mg may be considered as it dissolves immediately
in the mouth8 A single dose# or no more than !2 hours treatment should
be prescribed8 &lease refer to the Rapid .ran7uillisation &rocedure if
available8
*A838 If the patient is still showing symptoms of %&'( after 4* hours the
mental health services should be contacted for advice and assessment8
*A848 &atients with dementia who are already ta2ing an antipsychotic $without
a diagnosis of psychosis) or anticholinergic on admission should be
reviewed# and a care plan made to reduce and rationalise their
Antipsychotic prescribing for people with dementia 121111 &age of 1*
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NHS North Essex
medication8 If necessary the mental health services should be contacted
for advice8 'ee appendi3 1
*A858 If the patient is discharged from acute care any antipsychotic started in
hospital should be discontinued# or the 5& should receive a clear plan for
discontinuation within 4 wee2s8
*A8 If the patient was prescribed an antipsychotic on admission and the
diagnosis or indication was unclear but it was not stopped the 5& should
be advised in the discharge letter to review or refer to mental health
services for a diagnosis8
,0 Prescribing for NEP23 inpatients
*%818 An assessment and a provisional diagnosis should be made as soon as
possible after admission
*%828 All e3isting medication $both as prescribed and as actually ta2en) should
be reviewed and rationalised where possible8
*%838 Ihen other causes have been considered and treated and non-drug
therapies have been tried# prescribe appropriate medication for %&'( at
the lowest effective dose with a review date of not more than 2 wee2s
initially then 4-wee2ly intervals8
*%848 "are plans which include information about trigger factors# non-drug
therapies and strategies# and plans for medication reduction or review
should be revised regularly during the inpatient stay8
*%858 (ischarge planning should include plans for reduction and?or
discontinuation of antipsychotics and ben0odia0epines8 .his may not be
at the time of discharge as the patient will need time to recover and to
settle in their new environment or at home8
*%88 .he carers or families of the patient should be involved in the discussion
about treatment# and their comments ta2en into account8
*%8!8 &atients who leave inpatient care on antipsychotics or ben0odia0epines
but who do not have a long-term psychotic illness should have their
medicines reviewed by the 5& after discharge8 .he discharge letter
should be clear about the discontinuation plan8 .he care co-ordinator or
the community team person assigned to the patient should follow up after
3 months to see whether the discontinuation has happened# and contact
the 5& if not# and the consultant if necessary8
C0 Prescribing for NEP23 outpatients
Antipsychotic prescribing for people with dementia 121111 &age ! of 1*
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NHS North Essex
*"81 "arers or relatives should be invited to the appointment and involved in
the medicines review if possible8
*"82 A clear record of medicines history including all medication that is
actually ta2en and what is prescribed should be included in the outpatient
letter to the 5&8
*"838 &sychotropic medicines should be reviewed8 A plan should be made for
reduction in the community by the 5& if appropriate
*"848 Recommendation should be made to the 5& to review if non-
psychotropic medicines are li2ely to be causing adverse effects
$particularly increase in dementia and confusion# depression or pain#
delirium# or psychotic symptoms or %&'()
-0 Prescribing in primary care
*(81 Antipsychotics should only be initiated if all other methods have been
tried first8 Risperidone 511microgram 6 2mg daily should be first option
$not for patients with >ewy body dementia)8 +or patients with >ewy body
dementia or par2insonAs disease Duetiapine or Aripipra0ole have less
adverse effects8 $see appendi3 2)
*(828 In an emergency one of the above can be used as a single dose# or oral
Ealoperidol 511mcg-185mg if a recent -"5 showed no cause for
concern8 =lan0apine velotabs 5mg may be useful in an emergency if
swallowing is a problem8
*(838 Antipsychotics should not be included in repeat prescription schemes
unless there is a clear diagnosis of a long-term psychotic illness8
*(848 +or patients who have been prescribed antipsychotics but who do not
have a diagnosis of psychotic illness the medication should be reduced
or stopped as shown in section /8 If in doubt# refer to ,-&+. for advice8
*(5 &atients who have been prescribed antipsychotics by other organisations
or healthcare professionals and who do not have a long-term psychotic
illness should also be reviewed by the 5& $see section /)8 If in doubt
refer to ,-&+. for advice8
*(8 .he carers or families of the patient should be involved in the discussion
about treatment# and their comments ta2en into account8
4! $educing and discontinuing antipsychotics and ben5odia5epines
Antipsychotic prescribing for people with dementia 121111 &age * of 1*
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NHS North Essex
/818 If the antipsychotic has been prescribed for a patient with a diagnosis of
psychiatric illness# not 9ust %&'(# please do not discontinue without
referral to ,-&+. services8
/828 If the antipsychotic or ben0odia0epine has been prescribed for less than
a month it can be stopped without tapering off8
/838 If the patient does not have a diagnosis of psychiatric illness the
antipsychotic should be tapered off at 3 months or less over a period of 4
wee2s8 'mall doses can be stopped in a shorter time8
/848 'udden withdrawal can cause increased behaviour problems# nausea#
sweating# acute an3iety# nightmares# and poor sleep8
/858 &atients who have been prescribed antipsychotics or ben0odia0epines
for longer than a year should have them withdrawn more slowly $for
e3ample 4-wee2ly)8 .he dose can be halved for each step down to the
lowest dose recommended before stopping8 If withdrawal effects are
observed the dose should stay the same for another month before review
for further reduction8
/88 &atients who have been on long-term depot in9ections and who do not
have a diagnosis of psychiatric illness# should have the dose reduced
slowly# using the same dose interval8 'ymptoms of withdrawal may not
be evident for 1-3 months after discontinuation8
/8!8 &atients prescribed long-term depots and who have a diagnosis of
psychiatric illness should be reviewed by ,-&+. services if they have
not had a secondary care review within 1 year8
/8* &atients who do not have a diagnosis of psychosis but who have a
recurrence of symptoms even when treatment is withdrawn slowly should
be referred to ,-&+. services8
/8/8 .he patient should be regularly monitored for signs and symptoms of
relapse or withdrawal effects8
6! Practical points about discontinuation and planned dose changes
11818 &harmacy repeat systems and lead times mean that it will be difficult and
sometimes e3pensive to change medication 7uic2ly8 "onsideration
should be given to the urgency of the change8 "ould it be done at the
ne3t supply# rather than immediatelyJ
11828 .he pharmacy should be given a copy of the care plan so they can plan
ahead rather than dispense the same again in advance8
11838 +or patients in care homes#
Antipsychotic prescribing for people with dementia 121111 &age / of 1*
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NHS North Essex
.he 4edicines Administration "hart will need to be amended to effect the
change8
It must be clear who is going to amend the charts and to assign a person
at the home who is responsible for chec2ing that the changes have been
made according to the care plan8
A copy of the plan for changing medicines should be attached to the
4edicines Administration "hart8
11848 4onitored dosage systems $4(') or compliance aids
Antipsychotics and other drugs which are being changed on the care
plan could be pac2ed separately# not in the 4(' bo38 .his may have
training implications for the care home staff8
4(' bo3es or sheets are usually monthly# so ideally changes in
medication should be monthly the whole bo3 is the same# and to avoid
waste8
If several 4(' pac2s are sent at once they must be very clearly dated
as to when they should be used or the order in which they should be
used8
11858 "arers and families must be advised about withdrawal effects to be
aware of# when they should see2 professional advice# and contact
details for the appropriate professionals $ for e3ample the doctor# care
co-ordinator# memory clinic nurse# admiral nurse)
1188 .here may be good reasons why the planned changes need to be
amended8 .he care plan should state who will be responsible for
informing the relevant people when this happens8
118!8 It may be helpful to have electronic reminders on the 5& prescribing
system to remind them to review in 3 wee2s and to withdraw treatment
unless they are demonstrating clear and ongoing benefit8
! 3raining and support
3o be completed
#! Audit
"D"8
-sse3 "" registration of care homes8
&=4E;< audit 'eptember 2112
Antipsychotic prescribing for people with dementia 121111 &age 11 of 1*
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NHS North Essex
&! $eferences7 lin8s and further reading
18 ,I"- "5 (ementia 6 supporting &eople with (ementia and their "arers in Eealth and 'ocial
"are 211 amended 4arch 2111
28 .he use of antipsychotic medication for people with dementia@ .ime for action %aner9ee (E
128118211/
38 ,I"- &E51 4ental wellbeing and older people www8nice8org8u2?&E51
48 Al0heimerAs society
58 (ementia Action Alliance
http@??www8institute8nhs8u2?7ipp?callsKtoKaction?(ementiaKandKantipsychoticKdrugs8html
e-mail address for (ementia Action Alliance@ "2AdementiaLinstitute8nhs8u2
8 .raining
& 'est practice
guide for heal...
!8 =ptimising treatment
(ore principles
Dementia care....

(all)to)action)v*)
(%+S!)v*.pd...
,Optimising treatment and
care for people with behavioural and psychological symptoms of dementia 2011
*8 Information for hospital (octors www8insitute8nhs8u2?Eospital(octors"2A
/8 Information for occupational therapists http@??www8cot8co8u2?
118 Information for carers (oE312! Iho caresJ Information and support for carers of people
with dementia (ec 211 +rom dhLprolog8u28com 1*!11 555 455 +a3 1123 !24 524
Royal "ollege of psychiatry http@??www8rcpsych8ac8u2?files?pdversion?"R13*8pdf
http@??www8rcpsych8ac8u2?files?pdversion?cr11/8pdf
118 Earwood (8 5ood prescribing in dementia8 :anuary 211/ revised :anuary 2111
,E' Isle of Iight8
128 Eusebo %# %allard "# 'andvi2 R# ,ilson =# Aarsland8 -fficacy of treating pain to reduce
behavioural disturbances in residents of nursing homes with dementia@ cluster randomised
clinical trial %4:2111F343
Appendix
9ANAG"NG ,EHA:".;$A< .$ PS=CH.<.G"CA< S=9P3.9S
2.$ PE.P<E >"3H -E9EN3"A 1,PS-0

Antipsychotic prescribing for people with dementia 121111 &age 11 of 1*
Approved by 445 :an 2112 Review date :uly 2112
Patient has BPSD
(delusions, hallucinations,
agitation, aggression,
irritability, with decline in
cognition over 6/12
Delirium? (short
history <1 week,
confusion,
hallucinations,
delusions, fluctuating
cognition
Treat underlying acute
medical problems
eg!T", other infection,
adverse drug effects,
alcohol withdrawal
PAIN a##roach$ %anage or treat
P & Physical #roble's eg #ain, infection
A & (ctivity)related eg dressing, washing,
eating
I & "atrogenic eg *rug adverse effects
N & +oise, light, environ'ent
Non-drug approaches
eg distraction, activity, leave and
return, 1$1 care, 'usic,
aro'athera#y ,arer su##ort 'ay
hel# the' to co#e better
-nly consider drug treat'ent if #sychosis, de#ression or behaviour har'ful or
distressing to individual or others
Identify dominant symptom group
Psychosis: .allucinations, delusions
Depression: /ow 'ood, a#athy, loss of
en0oy'ent
Apathy: /ower 'otivation, listlessness, loss of
drive to engage in activities
Aggression, agitation, sleep problems,
other egse1ual disinhibition, stereoty#ical
'ove'ents
Consider type of
dementia and co-
morbidities
,onfir' diagnosis and
give a##ro#riate
treat'ent if /ewy
body/#arkinson2s
sus#ected
eneral guidelines for prescribing antipsychotic drugs in dementia (see
a##endi1 34 5ef$ Ti'e for (ction *o.
"f the #atient is not known to the de'entia service consider a referral This
will enable assess'ent for non)#har'acological thera#y and initiation of
cholinesterase inhibitors or 'e'antine if a##ro#riate
*e#ression and an1iety are co''on in de'entia, and an antide#ressant could
be first)line treat'ent before anti#sychotics
(void anti#sychotics for #eo#le with /ewy body de'entia or #arkinson2s if atall
#ossible
*iscuss risks and benefits with carers or relatives before #rescribing "nfor'
the' if #rescribing off)licence and docu'ent reasons clearly in the notes
5ecord the target sy'#to' to be 'onitored
/i'it length of #rescri#tion and set a review date
5efer to de'entia services if anti#sychotics need to be #rescribed for longer
than 2 weeks

NHS North Essex
Appendix #
P$ESC$","NG G;"-E<"NES 2.$ 9ANAG"NG ,EHA:".;$ 2.$ PE.P<E
>"3H -E9EN3"A
,on-drug strategies should be the first line treatment8
Antipsychotic prescribing for people with dementia 121111 &age 12 of 1*
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Al5heimer?s disease
9ain symptom
st
line -ose $e%iew #
nd
line -ose $e%iew
(epression "italopram
'ertraline
+luo3etine
5-21mg
51-211mg
$increased
wee2ly)
11-41mg
4?52
then
3?12
then
?12
4irta0epine 15-45mg
increased
2?52
4?52 then
3?12 then
?12
Apathy "italopram#
'ertraline
+luo3etine
5-21mg
51-211mg
11-41mg
As
above
(onepe0il#
Rivastigmine#
5alantamine
M>
5-11mg
185-mg
twice daily#
increasing
every 2?52
*-24mg
once daily
4onthly for
3?12# then
?12
&sychosis Risperidone
Ealoperidol
if -"5 is
recent and
=<
1825-2mg
daily
1825-1mg
=( or %(
Iee2ly
for 4?52#
then
monthly
for 2?12
then 3-
monthly
Duetiapine
=lan0apine
Aripipra0ole
Amisulpride
1285-
111mg
once or
twice a
day
285-5mg
daily
285-11mg
=(
51-311mg
daily
As for
Risperidone
Aggression As above Review
wee2ly
4oderate
agitation or
an3iety
"italopram 5-15mg
=(
2-wee2ly
for 3?12
then
?128
"hec2
-"5
.ra0odone
4emantine
Duetiapine
=lan0apine
51-151mg
5-21mg
daily#
increasing
by 5mg
wee2ly
1285-
111mg
daily
285-5mg
As for
"italopram
'evere
agitation?an3iety
after
antidepressant
trial
Risperidone
Ealoperidol
if -"5 is
recent
1825-2mg
daily
1825-2mg
daily
Iee2ly
review
Aripipra0ole
4emantine
Duetiapine
=lan0apine
285-11mg
'tart low
5-21mg
daily#
increasing
by 5mg
wee2ly
1285-
111mg
daily
285-5mg
Iee2ly
review
&oor sleep Nopiclone 38!5-
!85mg
Iee2ly
review
Nolpidem 5-11mg Iee2ly
review
:ascular dementia and stro8e'related dementia
"holinesterase inhibitors and 4emantine are not licensed for treatment of
vascular dementia and should not be used8 &rescribing of drugs with an
increased ris2 of cerebrovascular events# such as antipsychotics# should be
carried out with e3treme caution8
-ementia with <ewy bodies or Par8inson?s disease dementia
9ain
st
line -ose $e%iew #
nd
line -ose $e%iew
Antipsychotic prescribing for people with dementia 121111 &age 13 of 1*
Approved by 445 :an 2112 Review date :uly 2112

NHS North Essex
symptom
(epression "italopram 5-21mg 4onthly for
3?12 then
?12
'ertraline
$lower cardiac
ris2)
51-
211mg
4onthly for
3?12 then
?12
Apathy "italopram
'ertraline
5-21mg
51-
211mg
As above (onepe0il
Rivastigmine
5alantamine
M>
5-11mg
185-mg
%(
*-24mg
=(
As above
&sychosis
Can anti-
parkinson drugs
be decreased?
Duetiapine 1285-
111mg
Iee2ly for
4?52 then
monthly
(onepe0il
Rivastigmine
5alantamine
M>
Aripipra0ole
5-11mg
185-mg
%(
*-24mg
=(
285-
15mg
=4
Iee2ly for
4?52#
monthly for
2?12# then
?12

Aggression As above
4oderate
agitation or
an3iety
"italopram 5-21mg
start low
2-wee2ly#
then 3?12
(onepe0il
Rivastigmine
5alantamine
M>
5-11mg
185-mg
%(
*-24mg
=(
As above
'evere
agitation or
an3iety after
antidepressant
trial
Duetiapine 1285-
111mg
Iee2ly for
4?52 then
monthly
(onepe0il
Rivastigmine
5alantamine
M>
5-11mg
185-mg
%(
*-24mg
=(
As above
&oor sleep Nopiclone 38!5-!85
mg
Iee2ly Nolpidem 5-11mg Iee2ly
,ightmares#
hyperactivity
$poor R-4
sleep)
"lona0epam 185-1mg
at night
Iee2ly for
1?12# then
3?12
Appendix & Sample GP letter for discharge from caseload
Antipsychotic prescribing for people with dementia 121111 &age 14 of 1*
Approved by 445 :an 2112 Review date :uly 2112

NHS North Essex
(ear (octor#
I am writing to inform you that I am discharging patient name from my caseload8
.his patient is currently prescribed antipsychotic names! at dosage dose and
fre"uency which was commenced on date for
Choose one of the following
18 (ementia with psychotic features
28 (ementia with aggressive behaviour which was unresponsive to other
interventions
In accordance with the recommendations of &rofessor %aner9eeAs report we
would recommend discontinuation of antipsychotic names!
As name of patient had (ementia with Choose one of the following#
Bpsychotic featuresC or Baggressive behaviourC we would recommend that
he?she is reviewed at the practice in 3 months8 At that point it is recommended
that a Bbest interestsC assessment is made with regards to discontinuing the
medication8 =nce it has been decided to discontinue the medication we would
recommend a tapered withdrawal of the medication# re7uesting carers to
contact your surgery if there is any acute deterioration associated with this8 Ie
would also recommend a patient review once the medication has been
withdrawn8 If in this particular case you have concerns then please do not
hesitate to re-refer to us for supervision of the withdrawal8
$dd other diagnosis details and care plan
Current medication for mental health
$ll other current medication
Changes that have been made during inpatient stay or at outpatient clinic%
Oours sincerely
Antipsychotic prescribing for people with dementia 121111 &age 15 of 1*
Approved by 445 :an 2112 Review date :uly 2112

NHS North Essex
Appendix ( 9anaging beha%iour problems in people with dementia ' #('hour sleep and acti%ity chart
A record of when and how often behaviour problems occur may be helpful
to all who support the patient in planning their care8 &lease complete this
chart and bring it to your ne3t appointment or discuss it with
PPPPPPPPPPPPP88on $date!&&&&&&%
,ame of patient PPPPPPPPPPPP88 &erson completing PPPPPPPPPP
(ay H
(ate
*
am
/
am
11
am
11
am
12
am
1
pm
2
pm
3
pm
4
pm
5
pm

pm
!
pm
*
pm
/
pm
11
pm
11
pm
12
pm
1
am
2
am
3
am
4
am
5
am

am
!
am
&lease write any other comments overleaf
Antipsychotic prescribing for people with dementia 121111 &age 1 of 1*
Approved by 445 :an 2112 Review date :uly 2112
<ey@
Active involvement in tas2s?interests -
Restlessness# agitated A
Resting# settled R
'leeping '

NHS North Essex
Appendix ) 2low chart for memory clinics
A! -iagnosis Pro%isional diagnosis of
Al0heimerQs (isease with -arly =nset G?- +11811 with symptoms predominantly delusional
+11812 with symptoms predominantly hallucinatory
Al0heimerQs (isease with >ate =nset G?- +11811?+11812
Al0heimerQs (isease Atypical or 4i3ed .ype G?- +11821?+11822
Al0heimerQs (isease ;nspecified G?- +118/1?+118/2
Rascular (ementia of Acute =nset G?- +11811?+11812
4ulti-infarct (ementia G?- +11811?+11812
'ubcortical Rascular (ementia G?- +11821?+11822
4i3ed "ortical and 'ubcortical Rascular (ementia G?- +11831?+11832
=ther Rascular (ementia G?- +118*1?+118*2
(ementia in &ic2Qs (isease G?- +12811?+12812
(ementia in "reut0feldt-:acob (isease G?- +12811?+12812
(ementia in EuntingtonQs (isease G?- +12821?+12822
(ementia in &ar2insonQs (isease G?- +12831?+12832
(ementia in Euman Immunodeficiency Rirus $EIR) (isease G?- +12841?+12842
(ementia in =ther 'pecified (isease "lassified -lsewhere G?- +128*1?+128*2
;nspecified (ementia G?- +13811?+13812
"apacity of patient to understand diagnosis assessed8
A28 "f there is no e%idence of psychosis and antipsychotics are being considered for dementia with
problematic beha%iours then
-nvironmental factors e3amined and e3cluded
Acute confusional screen underta2en and reported as normal
44'- underta2en where possible and shows no significant decline
&hysical e3amination underta2en and reported as normal
%ehavioural assessment underta2en where possible and not indicating behavioural intervention would be
successful
4edication assessed for side-effects or interactions without evidence of contribution to behaviour
(ue consideration given to an3iolytics including ''RIQs and not considered appropriate
Antipsychotic prescribing for people with dementia 121111 &age 1! of 1*
Approved by 445 :an 2112 Review date :uly 2112
,! Patient doesn@t ha%e capacity
18 &roceed according to %est Interests paying
particular attention to 4"A &art 1 'ection 48
1A8 (iagnosis discussed with relative?carer
and appropriate information sheet given
1%8 4edication discussed with relative?carer
and appropriate information sheet given
A1 (iagnosis discussed with patient and appropriate information sheet given8
A2 .he need for antipsychotic therapy e3plained to and discussed with the patient
A3 Ris2s and benefits of antipsychotic therapy e3plained to and discussed with patient
A4 .he choice of antipsychotic considered appropriate for the patient has been discussed with the patient
including li2ely side-effects of the drugs and assessment of ris2 factors for (iabetes 4ellitus and
"ardiovascular (isease
A5 Iritten information sheet regarding antipsychotic given to the patient and the carer?advocate
A8 "hoice of first antipsychotic is agreed 9ointly with the patient
A!8 &atient offered the opportunity to agree an advanced plan?directive
A*8 %aseline physical health chec2s carried out if practical and recorded on monitoring sheet
Eeight Ieight %4I Abdominal 5irth
%lood pressure >ipids %lood 5lucose ; H -
>+. &rolactin -"5
#! Patient appears to decline medication
2A8"onsider 4ental Eealth Act
2% "onsider (=>' assessment if in hospital
&! Patient appears to be agreeable to medication

NHS North Essex
Antipsychotic prescribing for people with dementia 121111 &age 1* of 1*
Approved by 445 :an 2112 Review date :uly 2112
A11 Ris2 assessment completed
A11 Appointment made to review medication after *-12 wee2s at therapeutic dose $4 wee2s for A "hIs# 2
wee2s for inpatients)
A12 Inform 5& of date first prescribed
,o abnormalities that would prohibit
medication
+urther tests re7uired Refer to 5&?physicians
At /'# wee8 re%iew
A13 "linical Response to medication assessed8
A14 'ide-effects of current antipsychotic assessed
A15 Repeat physical monitoring8 (o further tests or refer to 5&?physician if there are abnormalities or if necessary
A1 "hec2 that a current ris2 assessment has been completed
"ontinue antipsychotic
medication
'et review date
5& informed of plan
'top
medication
Advise 5&
and patient
of care plan
(ischarge to 5& with plan to reduce and stop
medication
'end letter including standard wording $app83)
$esults of baseline chec8s re%iewed