Mühlbauer V, Möhler R, Dichter MN, Zuidema SU, Köpke S, Luijendijk HJ. Antipsychotics for agitation and psychosis in people with Alzheimer's disease and vascular dementia. Cochrane Database of Systematic Reviews 2021, Issue 12. Art. No.: CD013304. DOI: 10.1002/14651858.CD013304.pub2. Accessed 07 February 2022.

Picture this…

Chris’ father, Alec, was diagnosed with dementia several years ago.  Over the past few months, Alec’s symptoms have deteriorated, and he has moved into a care home that specialises in dementia care. Alec has found the move difficult and has been agitated and restless.  On Monday, when Chris went to visit, staff told him that his father had been shouting out in the night and the doctor was considering prescribing an antipsychotic medication. Chris is finding the situation very upsetting.  He has heard of antipsychotic medications being used to treat mental health conditions and would like to know more about whether they will help his father’s symptoms.

Summary messages –

• Typical antipsychotic medicines (such as haloperidol) might alleviate restlessness and aggression and may decrease delusions and hallucinations slightly in people with dementia.
• Atypical antipsychotic medicines (such as risperidone) probably reduce agitated behaviour slightly but have no effect on psychotic symptoms.
• Both typical and atypical antipsychotic medicines increase the risk of drowsiness and other unwanted events such as tremor, weight gain and death.
• In some studies improvements in symptoms were seen both in people who had been prescribed the antipsychotic medications and those who had not.
• Because the beneficial effects are likely to be small and the risk of unwanted effects high, it may be better to look for other treatment options and to investigate any possible underlying causes of agitation or psychosis.

What the research says –

Antipsychotics are medicines that are used to treat psychotic symptoms (for example delusions and hallucinations) in mental illnesses such as bipolar disorder, severe depression and schizophrenia. People living with dementia may also experience delusions and hallucinations.  They may also feel agitated and restless and may be aggressive towards others.  Although it is important to try and work out what the underlying causes of these types of behaviour are in people living with dementia, antipsychotic medications are sometimes given, particularly when the symptoms are severe. 

This systematic review published by Cochrane in December 2021, identified 24 studies with a total of 6090 people living in care homes, hospitals, in the community or in a combination of these settings.  The review authors wanted to collect evidence on how well antipsychotic medicines work in reducing agitation and psychotic symptoms.  They also wanted to know how often people living with dementia experienced unwanted effects after taking antipsychotics. Data were collected from randomised controlled trials that compared antipsychotic medicines with placebo (a ‘dummy’ pill) in people with the two commonest types of dementia: Alzheimer’s disease and vascular dementia. Six studies tested typical antipsychotics, 20 studies tested atypical antipsychotics and two tested both types of medication.

In the studies that investigated typical antipsychotic medicines, there was a slight improvement in psychosis symptoms compared with placebo but the effects on agitation were less clear. In the studies that investigated atypical antipsychotic medicines, there was a slight reduction in agitation and aggression, but little or no effect on psychosis symptoms. Both typical and atypical antipsychotic medicines led to an increase in drowsiness and movement disorders, alongside a risk of severe harmful effects or death.

Because of the small number of studies that investigated the effects of typical antipsychotics, we cannot be certain about the findings.  Furthermore, perhaps because these studies are quite old there is less information available on unwanted effects.  There is much more evidence available on the effects of the newer atypical antipsychotics which means that we can be more certain that these drugs only have a small effect on agitation and little or no effect on psychosis.

Where is Chris now…

Chris discussed his fathers’ symptoms with the care home staff and the old-age psychiatrist who is taking care of him.  They are investigating other possible medical causes for Alec’s distress including constipation (something he has suffered with in the past). Over the last few nights, Alec has been much more settled.  The old-age psychiatrist has reassured Chris that she will only prescribe an antipsychotic medication as a last resort if Alec or the people around him are at risk of harm.

Yuan Chi

Information Specialist, Cochrane Campbell Global Ageing Partnership

Please note: the stories and pictures used do not represent specific individuals – they are merely utilised to contextualise the data into a more digestible format 

Reference points –

Mühlbauer V, Möhler R, Dichter MN, Zuidema SU, Köpke S, Luijendijk HJ. Antipsychotics for agitation and psychosis in people with Alzheimer's disease and vascular dementia. Cochrane Database of Systematic Reviews 2021, Issue 12. Art. No.: CD013304. DOI: 10.1002/14651858.CD013304.pub2. Accessed 07 February 2022

If  you have any comments regarding this blog post, please contact us at  globalageing@cochrane.org.   We would love to hear your thoughts and answer any questions you may have. 

Web editor: Monserrat Conde