More than 25 million people worldwide have dementia, with a new case developing every seven seconds.1 While putative disease modifying agents are being developed, we are limited to symptomatic treatments for cognitive and non-cognitive features. Non-cognitive symptoms—referred to as behavioural and psychological symptoms of dementia—including agitation, psychosis, depression, and aggression, occur in up to half of those with dementia in the community and an even higher proportion in residential care. Antipsychotics have been widely prescribed off licence for these symptoms, and 20-50% of people with dementia in institutional care receive them.2 What is the evidence for their efficacy?

Several placebo controlled, randomised controlled trials (RCTs), especially of newer “atypical” antipsychotics like risperidone, show an improvement in agitation, aggression, and psychosis.3 But, even before current concerns over their side effects, the strength of the evidence supporting widespread prescribing in dementia was questioned. Efficacy is modest, and most studies have assessed behavioural and psychological symptoms of dementia as a general outcome rather than targeting specific symptoms.

Side effects include extrapyramidal features, sedation, metabolic disturbances, increased cognitive impairment, and …