Aging brings many changes that can be unpleasant, from losing mobility to needing help with tasks that used to be easy.
For those with Alzheimer’s disease and other forms of dementia, these challenges often are even greater as the disease steals their ability to communicate their needs and preferences. Just like for anyone else, people with these progressive cognitive disorders may express frustration with anger, aggression or agitation. Those strong and difficult-to-manage emotions, however, can sometimes become overwhelming for their caregivers.
In some instances, caregivers may turn to medications, such as antipsychotics, to help quell the difficult or combative behaviors. But this isn’t a risk-free solution. These powerful medications have side effects that can become dangerous when used inappropriately.
What Are Antipsychotic Drugs?
Sometimes called “chemical straightjackets,” antipsychotics are a class of prescription medications that are used to treat psychotic symptoms such as delusions (false beliefs) and hallucinations (false sensations) in people who have schizophrenia, bipolar disorder or major depression with psychotic features.
However, for people with dementia, their use may not be appropriate, and overuse or abuse of these medications in seniors without a preexisting psychotic condition can be dangerous.
Unfortunately, it’s not uncommon for nursing homes to use antipsychotic drugs. A 2021 New York Times investigation that revealed at least 21% of nursing home residents, more than 225,000 people in total, were on antipsychotic drugs.
Additionally, the percentage of nursing home patients who receive antipsychotic drugs is one of the measurements U.S. News uses in its ratings for Best Nursing Homes.
[READ: New Treatments for Alzheimer’s Disease.]
Why Antipsychotics Are Sometimes Used in Long-Term Care Settings
For older Americans who develop dementia, memory loss is the hallmark symptom. But many other symptoms can develop as well.
“We also see changes in people’s ability to control their impulses and their ability to make good decisions as they get older,” says Dr. Katherine Brownlowe, a neuropsychiatrist and clinical associate professor of psychiatry and behavioral health with the Ohio State University Wexner Medical Center in Columbus.
Over time, behavioral issues, confusion and an overall loss of ability to care for oneself worsen, and the delusions, hallucinations and paranoia that can develop in later-stage dementia may lead to angry outbursts or other behaviors that are hard to manage, similar to those seen in psychotic conditions.
These symptoms cause distress for the patient as well as the caregivers and can decrease quality of life. Particularly in understaffed nursing homes, caring for an agitated or noncompliant patient becomes very difficult.
Unfortunately, there aren’t many options for treating these symptoms when they’re caused by dementia.
Sold under the brand name Rexulti, brexpiprazole is the first and only U.S. Food and Drug Administration-approved antipsychotic medication available to treat agitation due to dementia associated with Alzheimer’s disease.
Medications like Seroquel (quetiapine), Zyprexa (olanzapine) and Abilify (aripiprazole) aren’t approved for use to address dementia-induced difficult behaviors, such as combativeness from a patient exhibiting intractable behaviors or experiencing delusions, hallucinations or paranoia. However, they are sometimes prescribed off-label.
“Nursing homes are understaffed, and it is difficult to manage patients who are uncooperative or unruly,” says Dr. Aron Tendler, who is board certified in psychiatry, sleep medicine and obesity medicine and is the chief medical officer of Graymatters Health, a mental health-focused technology company in Haifa, Israel.
[READ: 8 Health Problems That Can Mimic Dementia]
Risks of Antipsychotic Use in Nursing Homes
Antipsychotics can pose significant health risks for older adults. For instance, haloperidol (Haldol) is a sedative antipsychotic medication that carries an FDA warning. When used in elderly patients with dementia-related psychosis, Haldol significantly increases the risk of death from heart problems, falls and infections.
For this reason, Haldol is not approved for use in patients with dementia-related psychosis. Rather, it is intended to treat schizophrenia.
The New York Times investigation, however, found that some nursing homes are adding a diagnosis of schizophrenia to a patient’s chart in order to get around this restriction. This means the use of the medication doesn’t have to be reported to Medicare and, thus, improves the standing of the facility in various agency records and rankings.
According to the investigation, 1 in 9 people in nursing homes have received a schizophrenia diagnosis. In contrast, in the general population, the condition affects about 1 in 150 people, and it’s almost always diagnosed prior to age 40.
The problem also appears to have a socioeconomic dimension, according to an April 2024 study in JAMA Network Open. That study found that inappropriate use of antipsychotics in nursing homes occurs at a higher rate in nursing homes with low staff-to-patient ratios that are located in disadvantaged areas.
However, simply banning the use of such medications isn’t the answer, as they can be helpful tools for people who truly need them.
[READ: 7 Stages of Alzheimer’s: What to Expect]
Start With Nonpharmacologic Interventions
For those who have a legitimate diagnosis where an antipsychotic medication can improve their quality of life, these medications must remain accessible. But in people with dementia, antipsychotics should only be used if behavioral methods are ineffective, with consent from the legal guardian.
“It’s not appropriate to use antipsychotics if patients can be managed with less risky methods,” Tendler adds.
Behavioral interventions can take a number of forms.
“Interventions like these are designed to redirect the person into something purposeful,” says Lisa Skinner, a Napa, California-based behavioral expert in the field of Alzheimer’s disease and related dementias. “We all need to feel that we have a purpose in life. Even people who suffer from dementia need to have that feeling too. That’s why these types of things should be offered to them.”
Non-drug interventions for dementia include:
— Music therapy. Music activates certain parts of the brain and can often transport someone to a previous time in their life via memories associated with the music. This effect can be calming in some people with dementia.
— Emotional reassurance. The Alzheimer’s Association recommends taking a moment to reassure someone with dementia if they become agitated. The organization advises backing off, asking permission to assist the person, remaining calm and offering positive, reassuring statements.
— Distraction and engagement in meaningful activity. Distraction activities that help engage a person with aspects of their former life can be helpful. For example, a great activity for somebody that was a homemaker is to offer them a basket of towels and ask them to fold them, Skinner says. The activity can be soothing while giving the person a sense of purpose.
FAQ: Questions to Ask For Your Loved One
Because the use of antipsychotics in nursing homes remains an ongoing concern, it’s important to check in with nursing home care staff regularly.
Brownlowe recommends asking the following questions to determine whether your loved one is being treated appropriately.
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Antipsychotic Drugs in Nursing Homes originally appeared on usnews.com
Update 11/15/24: This story was previously published at an earlier date and has been updated with new information.
