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

BMJ 2014; 349 doi: (Published 03 November 2014) Cite this as: BMJ 2014;349:g6420
  1. Anne Corbett, lecturer in dementia research1,
  2. Alistair Burns, professor of old age psychiatry2,
  3. Clive Ballard, professor of age related diseases1
  1. 1Wolfson Centre for Age-Related Diseases, King’s College London, London, UK
  2. 2University of Manchester, Manchester M13 9NT, UK
  1. Correspondence to: C Ballard clive.ballard{at}

The bottom line

  • Despite continued use of antipsychotics to treat agitation and aggression in people with dementia, there is limited evidence of clinically meaningful benefit

  • The potential harms of antipsychotic use (including increased cerebrovascular events and mortality) outweigh the benefits

  • Risperidone is the only recommended antipsychotic, and should be used only in people with dementia who have pre-existing psychotic disorders or severe aggression. It should be prescribed for no more than 12 weeks

  • Careful monitoring is the best practice alternative, with evidence that alternative treatments including analgesia and non-drug based approaches provide effective options

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.1 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.2 3

Sources and selection criteria

This article is based on an updated review of the literature published in systematic reviews. We searched the electronic databases PubMed, Embase, and the Cochrane Library. We evaluated individual randomised controlled trials from systematic reviews to calculate the specific attributable risk of key adverse events associated with risperidone in people with Alzheimer’s disease. Studies were selected according to the …

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