The Overuse of Antipsychotics in Alzheimer’s and Dementia Patients

By: Armanda Dervishi, PharmD Candidate ‘27

Introduction

Dementia is a progressive syndrome characterized by a decline in memory, reasoning, and daily functioning. Symptoms often include changes in personality, mood, and behavior, alongside cognitive decline. The most common form is Alzheimer’s disease, which accounts for approximately 60-80% of all dementia cases.¹ Other subtypes include vascular dementia, Lewy body dementia, and frontotemporal dementia. Alzheimer’s disease currently affects approximately 7 million Americans, with nearly 1 in 3 older adults dying with Alzheimer’s disease or another dementia.² The cost of care in the U.S. exceeds $360 billion annually, most of which is borne by unpaid family caregivers.²

Despite being common, dementia is not a normal part of aging, and risk is influenced by factors such as the APOE ε4 allele, cardiovascular health, and lifestyle.³ In addition to memory impairment and language difficulties, patients frequently develop behavioral and psychological symptoms of dementia (BPSD), including agitation, aggression, delusions, hallucinations, depression, and sundowning.⁴ These symptoms are often the most distressing aspect of dementia for families and a major reason for nursing home placement. In clinical practice, antipsychotics are often prescribed off label to manage behavioral and psychological symptoms of dementia. However, their widespread use raises significant safety concerns.

Antipsychotic Use in Alzheimer’s and Dementia

Second-generation (atypical) antipsychotics such as risperidone, olanzapine, and quetiapine are among the most commonly prescribed medications for Alzheimer’s and dementia patients. Although partial symptom relief may occur, benefits are often outweighed by clinically significant risks. In 2005, the FDA issued a black box warning that all antipsychotics increase mortality in elderly patients with dementia-related psychosis, with causes of death most commonly linked to cardiovascular events and infections.⁵ In addition to increased mortality, antipsychotics are associated with sedation, orthostatic hypotension, falls, extrapyramidal symptoms, and metabolic complications. For patients with Alzheimer’s disease who already face progressive cognitive decline and frailty, these adverse effects can further accelerate loss of function and reduce quality of life.

Guideline Recommendations

The American Geriatrics Society (AGS) Beers Criteria strongly recommends avoiding antipsychotics for behavioral problems of dementia unless nonpharmacologic strategies have failed and the patient poses a serious risk of harm to themselves or others.⁶ When antipsychotic use is deemed necessary, clinicians should use the lowest effective dose for the shortest possible duration.

Similarly, the Centers for Medicare & Medicaid Services (CMS) requires that nursing facilities document attempted non-pharmacologic interventions and perform gradual dose reductions at least twice a year, unless contraindicated. ⁷ Preferred alternatives include non-drug strategies such as caregiver education, consistent routines, structured activities, environmental modifications, and the use of music or aromatherapy.⁴ These interventions may require more time and effort than medication, but they avoid the substantial harms associated with antipsychotics.

The Pharmacist’s Role

Pharmacists play a critical role in preventing unnecessary antipsychotic use. During medication reviews, pharmacists should identify patients with Alzheimer’s or dementia who are prescribed antipsychotics and assess whether nonpharmacologic interventions have been adequately attempted.

Case Example:

Mrs. Green, an 82-year-old woman with Alzheimer’s disease, was started on quetiapine 25 mg nightly for agitation. Within a few weeks, she became excessively drowsy and had two near-falls. The pharmacist reviewed her medications and identified quetiapine as a likely contributor.  The pharmacist communicated these concerns to the prescribing physician and recommended considering a gradual taper while implementing nonpharmacologic approaches such as structured evening activities and environmental modifications. In collaboration with the prescriber, the medication was tapered, and Mrs. Green’s alertness improved.

This scenario underscores the essential role of pharmacists in identifying risks and collaborating with prescribers to optimize patient safety and outcomes.

Conclusion

Antipsychotics remain widely used in Alzheimer’s disease and dementia despite their modest benefits and well-documented risks. Evidence consistently shows an increased risk of mortality, stroke, sedation, and falls in this vulnerable population. Current guidelines stress prioritizing non-drug interventions and limiting pharmacologic therapy to patients with severe, dangerous behavioral symptoms. Pharmacists play a crucial role in this process. By identifying inappropriate use, educating caregivers, and collaborating with prescribers, pharmacists can reduce unnecessary antipsychotic exposure and promote safer, evidence-based care. Through deprescribing efforts and patient-centered education, pharmacists help protect quality of life for patients with Alzheimer’s disease and related dementias.

References

1. CDC. About Dementia. Alzheimer’s Disease and Dementia. Published October 25, 2024. https://www.cdc.gov/alzheimers-dementia/about/index.html?utm_source=chatgpt.com
2. Alzheimer’s Association. 2024 Alzheimer’s Disease Facts and Figures. Alzheimer’s & Dementia. 2024;20(5):3708-3821. doi:https://doi.org/10.1002/alz.13809
3. National Institute On Aging. Alzheimer’s Disease Genetics Fact Sheet. National Institute on Aging. Published March 1, 2023. https://www.nia.nih.gov/health/alzheimers-causes-and-risk-factors/alzheimers-disease-genetics-fact-sheet
4. National Institute on Aging. Alzheimer’s Caregiving: Managing Personality and Behavior Changes. National Institute on Aging. Published July 11, 2024. https://www.nia.nih.gov/health/alzheimers-changes-behavior-and-communication/alzheimers-caregiving-managing-personality-and
5. Mortality and Antipsychotic Use in Dementia-Related Behavioral Disorders. Margolis Institute for Health Policy. Published 2024. Accessed September 2, 2025. https://healthpolicy.duke.edu/events/mortality-and-antipsychotic-use-dementia-related-behavioral-disorders
6. American Geriatrics Society. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7). doi:https://doi.org/10.1111/jgs.18372
7. State Operations Manual Appendix PP -Guidance to Surveyors for Long Term Care Facilities Transmittals for Appendix PP. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf

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