Deprescribing a long-term antipsychotic for behavioural and psychological symptoms of dementia

Patients taking an antipsychotic long term (for 12 weeks or longer) for a behavioural and psychological symptom of dementia (BPSD) can usually stop the antipsychotic without their symptom worsening. Rarely, patients will experience a worsening of symptoms if their symptoms were initially severe (eg psychotic features, violent aggression)—seek expert (eg psychiatrist, neurologist, geriatrician) advice before deprescribing. Patients whose symptoms were not initially severe can become less agitated when the antipsychotic is stopped.

Note: If symptoms were not initially severe, agitation can improve when the antipsychotic is stopped.

If an antipsychotic has been used to treat behavioural and psychological symptoms of dementia for 12 weeks or longer, begin deprescribing if:

Simultaneously engage in shared decision making with the patient or their substitute decision-maker and, if they consent , their family, carers or significant others. Discuss:

  • the role of antipsychotic therapy in achieving the patient’s treatment goals
  • the deprescribing process (see below), including that it is a trial and the antipsychotic can be restarted if required
  • any fears and concerns the patient or their substitute decision-maker, family, carers or significant others have about deprescribing
  • the benefits and harms of deprescribing. Potential benefits include improvements in cognition and behaviour, and a reduced risk of mortality, falls, fractures, cerebrovascular events and other adverse effects. Potential harms include worsening of behavioural symptoms and withdrawal effects if the antipsychotic is stopped too abruptly; however, these responses are uncommon.

On the basis of these discussions, collaboratively develop a plan1 that sets out the approach to monitoring, dosage adjustment, optimising nonpharmacological management (which is especially important if symptoms re-emerge) and indicators for restarting an antipsychotic. Involve relevant healthcare professionals in the plan’s development.

Despite limited evidence that it is safe to abruptly stop an antipsychotic used long term for behavioural and psychological symptoms of dementia, it may be preferable to slowly reduce the dosage to reduce the risk of behavioural symptoms worsening and antipsychotic withdrawal symptoms. Reduce the dose by 25 to 50% every 1 to 2 weeks until the lowest practical dose is reached, then after 1 to 2 weeks, stop the antipsychotic. Consider a slower dosage reduction schedule for patients who were taking a high dose of an antipsychotic or who had severe symptoms initially.
During dose reduction, assess target symptoms and monitor for withdrawal symptoms every 1 to 2 weeks (ie every time a dose reduction is made) or more frequently if the patient was taking a high dose of an antipsychotic or had severe symptoms initially. If target symptoms become significant or severe withdrawal adverse effects occur, consider restarting the antipsychotic at the minimum effective dose and re-trial deprescribing after 3 months.
1 A tool to facilitate antipsychotic review and deprescribing for behavioural and psychological symptoms of dementia has been created by NPS MedicineWise and is available here.Return