Antipsychotic medications are used extensively in nursing facilities. Their clinical benefits — when used for approved disease states (i.e., schizophrenia, Huntington’s disease, and Tourette’s syndrome) — are widely accepted. In individuals with a predetermined or long-standing history of mental illness, the chronic use of an antipsychotic medication also may be deemed necessary to stabilize and improve functionality. Sometimes antipsychotic medications are prescribed for off-label use in Alzheimer’s disease and other dementia-related illnesses where the effectiveness of the treatment can show mixed results. The off-label use of antipsychotic medications for dementia-related illnesses is unsupported in the literature.
In residents who are elderly with dementia, antipsychotics are only appropriate in a small number of instances. Yet, despite Food and Drug Administration warnings of increased mortality, the use of antipsychotics as a chemical restraint in nursing home residents who have dementia still persists. Significant morbidity — including higher blood sugar and cholesterol levels, weight gain, increased risk of falls, and decreased cognition — also are associated with the use of antipsychotics. In addition, these complications can lead to or cause a worsening of other primary diagnoses known to affect older adults.
This webpage includes best practice guidelines, tools, handouts, presentations and references for antipsychotic medications and alternatives to dementia care.
Evidence-based Best Practice for Antipsychotic Medications (PDF)
Developed by pharmacists in the Texas Department of Aging and Disability Services (DADS) Quality Monitoring Program, this resource provides evidence-based best practice guidelines for addressing management of antipsychotic medication use in the long-term care setting.
Antipsychotic Medications and Dementia Care (PDF)
Compiled by pharmacists in the DADS Quality Monitoring Program, this resource provides information about antipsychotic medications prescribed for the off-label use in treating behaviors associated with dementia. Typical and atypical medications and their side effects are discussed.
Reducing Unnecessary Antipsychotic Medications (PDF)
Compiled by pharmacists in the DADS Quality Monitoring Program, this resource provides information for routinely monitoring antipsychotic drug usage, dosages, gradual dose reductions, the outcomes of those reductions on behaviors, and suggested timeframes for conducting dose reductions.
Alternatives to Antipsychotic Medications (PDF)
Compiled by pharmacists in the DADS Quality Monitoring Program, this resource discusses the stages of cognitive impairment, the components of a behavior management program, causes of behaviors such as medical conditions and environmental triggers, suggestions for alternatives, and monitoring the results of using alternatives.
Antipsychotics: What’s the Big Deal? (PDF)
This presentation was developed by pharmacists in the DADS Quality Monitoring Program. It includes types of antipsychotic medications, side effects, prescribing considerations, risk factors with dementia, behaviors, and quality of life issues.
Sane Use of Psychotropic Medications (PDF)
This presentation was developed by Dr. Steven Levenson, MD, CMD, and addresses behaviors, altered mental status and treatment options.
Antipsychotic Medication Tracking Tool (PDF)
This tool, developed by pharmacists in the DADS Quality Monitoring Program, is to assist nursing home staff in their efforts to reduce the inappropriate use of psychotropic medications. This tool can be helpful in documenting pre-psychotropic medication root-cause analysis, promoting a proper decision-making process by identifying targeted behaviors, adjusting dosages accordingly, and reducing the length of time in which unnecessary medications remain within an individual’s drug regimen. The target audience is clinical staff.
Antipsychotic Education Form (PDF)
An educational form developed by DADS Quality Monitoring Program pharmacists, this teaching form includes the potential benefits, risks, and burdens of antipsychotic medications, and alternatives to antipsychotic medications.
Approved Indications for Antipsychotic Medications (PDF)
This handout was compiled from the 2013 revisions to Appendix P and PP of the State Operations Manual (SOM) naming the approved indications for antipsychotic medications, as well as the inadequate indications for treating behavioral or psychological symptoms of dementia (BPSD) with antipsychotic medications.
Be DADS Wise with the Use of Antipsychotics (PDF)
Developed by the pharmacists from DADS Quality Monitoring Program, this handout provides helpful information about antipsychotic medications and reducing the inappropriate use of these drugs in long-term care.
Behavioral or Psychological Symptoms of Dementia (BPSD) (PDF)
A handout developed by DADS Quality Monitoring Program pharmacists, it is a guide for antipsychotic medication use in long-term care.
Basic Guidelines for Quarterly Psychotropic Medication Evaluation (PDF)
A handout developed by DADS Quality Monitoring Program pharmacists, it provides guidance for conducting quarterly psychotropic medication evaluations and evaluating the effectiveness of non-pharmacological behavior interventions.
Basic Guidelines for Behavior and Side Effect Monitoring (PDF)
A handout developed by DADS Quality Monitoring Program pharmacists, it describes techniques for conducting effective behavior and medication side effect monitoring.
Diagnostic Checklist Clues to Identifying Causes of Common Behavior and Psychiatric Disturbances (PDF)
This tool was developed by Dr. Steven Levenson, MD. It was adapted from Chapter 2; Peter V. Rabins and Phillip R. Slavney: Overview of Psychiatric Symptoms and Syndromes. In Lyketsos, C., Lipsey, J., Rabins, P., and Slavney, P. Psychiatric Aspects of Neurological Diseases. New York: Oxford University Press, 2008. The tool can be used as a guide to match up findings related to the resident with known patterns and combinations of symptoms that may suggest a specific diagnosis. Because so many behavior and psychiatric symptoms are non-specific, symptom combinations and a chronological story are essential to identify the right cause, and thus to the right interventions. The idea is to rule out conditions in roughly the order listed (starting with delirium), unless the conclusion is obvious.
Updated: July 28, 2015