Evidence context

The NICE/SCIE guideline on dementia (which is being updated, publication expected June 2018) gives recommendations on the care of people with all types of dementia. This includes managing behavioural and psychological symptoms of dementia. The NICE quality standards on dementia and supporting people to live well with dementia describe concise sets of prioritised statements designed to drive measurable quality improvements within these areas. A NICE Pathway on dementia brings together all related NICE guidance and associated products on dementia in a set of interactive topic-based diagrams. See the NICE clinical knowledge summary on dementia for a general overview of the condition.

The risks and limited benefits of using first (typical) and second (atypical) generation antipsychotic drugs for treating dementia in people who exhibit challenging behaviours are well recognised. They have been the subject of several previous reviews and MHRA warnings, collated in the May 2012 edition of Drug Safety Update.

The NICE/SCIE guideline recommends that people with dementia who develop non-cognitive symptoms that cause them significant distress or who develop behaviour that challenges should be offered an assessment at an early opportunity to establish likely factors that may generate, aggravate or improve such behaviour. The assessment should be comprehensive and include for example, the person's physical health, depression, undetected pain or discomfort, side effects of medication, psychosocial factors, physical environment factors, and the person's religious beliefs and spiritual and cultural identity. Individually tailored care plans that help carers and staff address the behaviour that challenges should be developed, recorded in the notes and reviewed regularly.

For people with all types and severities of dementia who have comorbid agitation, the NICE/SCIE guideline recommends that non-pharmacological approaches may be considered including aromatherapy, multisensory stimulation, therapeutic use of music or dancing, animal-assisted therapy, and massage.

The NICE/SCIE guideline advises against the use of any antipsychotics for non-cognitive symptoms or challenging behaviour of dementia unless the person is severely distressed or there is an immediate risk of harm to them or others. Any use of antipsychotics should include a full discussion with the person and carers about the possible benefits and risks of treatment. In the May 2012 edition of Drug Safety Update, the MHRA advised that no antipsychotic (with the exception of risperidone in some circumstances) is licensed in the UK for treating behavioural and psychological symptoms of dementia. However, antipsychotics are often prescribed off-label[1] for this purpose.

SCIE have recently published the compassion intervention manual (requires log in) which aims to improve end of life care for people with dementia in care homes. It covers how to manage mental health, behavioural and psychological symptoms in detail, including many non-pharmacological interventions. This manual also states that, in severe agitation or distress, antipsychotic medications may need to be considered but these should only be initiated under specialist supervision.

In September 2010, the Department of Health published Quality outcomes for people with dementia: building on the work of the national dementia strategy, which is an implementation plan for their guidance Living well with dementia: a national dementia strategy. These resources build on the NICE/SCIE guideline and include strategies to reduce inappropriate prescribing of antipsychotics. In the May 2012 edition of Drug Safety Update the MHRA provided the following advice for health and social care professionals:

For prescribers considering using antipsychotics in people without a current prescription:

  • Carefully consider, after a thorough clinical examination including an assessment for possible psychotic features (such as delusions and hallucinations), whether a prescription for an antipsychotic drug is appropriate.

For prescribers considering continuing antipsychotics in people with a current prescription:

  • Identify and review people who have dementia and are on antipsychotics, with the purpose of understanding why antipsychotics have been prescribed.

  • In consultation with the person, their family and carers, and clinical specialist colleagues such as those in psychiatry, establish: whether the continued use of antipsychotics is appropriate; whether it is safe to begin the process of discontinuing their use; and what access to alternative interventions is available.

A Cochrane review, which was discussed in NICE's medicines evidence commentary on dementia: withdrawal of antipsychotic drugs in people with behavioural and neuropsychiatric symptoms, evaluated the effect of withdrawing treatment with antipsychotic drugs prescribed for behavioural and neuropsychiatric symptoms in people with dementia. It concluded that these can be withdrawn without detrimental effects on behaviour in many people. This review is consistent with the NICE/SCIE guideline.

A further NICE medicines evidence commentary on Alzheimer's disease: effect of citalopram on agitation discussed the efficacy and safety of off-label citalopram for treating agitation in people with Alzheimer's disease.

In March 2016 the Department of Health published the Challenge on dementia 2020: implementation plan, which sets out more than 50 specific commitments that aim to make England the world-leader in dementia care, research and awareness by 2020. The plan sets out priority actions across 4 themes: risk reduction; health and care; awareness and social action; and research. The Department of Health is working with SCIE to create a set of films demonstrating and promoting effective practice in person-centred care as the method for managing distress and challenging behaviours among people with dementia.

A separate key therapeutic topic is available on psychotropic medicines in people with learning disabilities whose behaviour challenges.

Practice examples and shared learning

There is a NICE shared learning example relating to this key therapeutic topic on prescribing antipsychotic medications for the treatment of behavioural symptoms in people with dementia, Milton Keynes 2012.

[1] In line with the guidance from the General Medical Council (GMC) on prescribing unlicensed medicines, the prescriber should take full responsibility for determining the needs of the patient and whether using a medicine outside its authorised indications is suitable.