Don't use antipsychotics routinely to treat agitation and aggression in people with dementia.

Behavioural and psychological symptoms of dementia such as agitation and aggression are commonly treated with atypical antipsychotic drugs, which are associated with severe side effects. However, there is increasing evidence of potential harms associated with use of these drugs in people with dementia, and guidelines increasingly recommend restricting their use. In Europe, only risperidone is currently licensed for use in dementia and only for up to six weeks in patients with severe aggression, defined as causing risk or severe distress, which has not responded to other treatments. No antipsychotics are approved for this patient group in the United States. Best practice guidelines, including National Institute for Health and Care Excellence guidelines in the United Kingdom and American Psychiatric Association guidelines in the US, are similar. However, they do not distinguish between individual atypical antipsychotics and recommend a maximum treatment period of 12 weeks, except in exceptional circumstances. 3 The use of these drugs in people with dementia has decreased worldwide in the past decade. For example, a 2012 audit in the UK indicated a 50% reduction in prescriptions, although 16% of people with dementia continued to receive antipsychotic treatment. Use is mostly off-licence, either prescriptions of antipsychotics such as quetiapine, olanzapine, aripiprazole, and haloperidol without a licence indication or the use of risperidone outside the strict licence indication. In addition, prescriptions often exceed the six week period specified in the licence indication for risperidone or the 12 week prescription period recommended in all of the major best practice guidelines, with 62% of people receiving atypical antipsychotics for six months or more. Although current guidance promotes more judicious use of these drugs, with regular review of prescriptions, the guidelines are difficult to interpret, particularly as thresholds for severity are unclear. The evidence for change Modest short term clinical benefit