Table 3.
Themes and highlights of statements addressed in the practice guideline for antipsychotic prescription in dementia patients residing in long-term care
| 1. General prescription stipulations. |
| • Antipsychotics should never be used as a first-line approach. Non-pharmacological interventions should be tried first. The benefits should be expected to outweigh the adverse events. |
| • APs should only be prescribed in |
| (a) symptoms caused by underlying psychotic disorder that causes severe distress to patient/risk to others, |
| (b) in non-psychotic patients in an extreme and acute situation with risk i.e. severe and harmful physical aggression to oneself or other, severe physical exhaustion, and severe eating/drinking disorders with a risk of malnourishment or dehydration. |
| • The behavior is not caused by another somatic disorder (such as pain, infection, hunger, constipation) or psychiatric disorder (anxiety/depression), |
| • only antipsychotics with proven evidence should be prescribed, |
| • start low, go slow. |
| 2. Assessment prior to prescription. |
| • Investigation of underlying syndromes, neurological, psychiatric, environmental (interaction) factors. |
| • Assessment of medical state and risk (cardiovascular and subtype of dementia (Lewy Body/Parkinson) and symptoms (motor symptoms, cardiac arrhythmias, orthostatic hypotension, urine retention). |
| • ECG should be carried out in patients with history of cardiovascular diseases, cardiac arrhythmia, and combination of medication that prolong QT-interval. |
| 3. Care and treatment plan. |
| • Use APs always in combination with non-pharmacological and preventive measure aimed at increasing carers competence. |
| • Care and treatment plan should draw expertise form multidisciplinary team/with regular consultation. |
| • Family caregiver should be informed and consulted throughout treatment and discontinuation. |
| • Improvement and lack of improvement should be included as a clinical criterion for modifying care and treatment plan. |
| 4. Discontinuation. |
| • Discontinuation should be a standard principle as part of a withdrawal plan. |
| • If APs are prescribed for sedative purposes, drug should be withdrawn when situation has calmed down. |
| • Discontinuation through tapering rather than immediate discontinuation unless Malign Neuroleptic Syndrome, cardiovascular complication, infections, severe side effect at low dose. |
| 5. Long-term treatment (> 12 weeks). |
| • Long-term antipsychotic treatment is only acceptable in patients with |
| ○ long history or high severity of psychotics/concurrent schizophrenia, |
| ○ at least two unsuccessful discontinuation attempts + psychosocial interventions has been shown not to be effective + alternative medication is not available/has been shown ineffective/expected to cause severe adverse events. |
| • Restarting can be acceptable – under supervision of a specialist – in extreme situation in case of |
| ○ recurrence of severe symptoms after withdrawal resulting in risk/distress that had previously improved with AP treatment, |
| ○ recurrence of severe symptoms after withdrawal if withdrawal was before completing a 12-week course, |
| ○ a distinct separate new episode. |