Antipsychotics prescribing in dementia often goes against dose and duration advice

Thousands of people with dementia are taking antipsychotic medications for longer than the NICE-recommended period of one to three months, researchers have found.

Researchers at University College London also found the drugs are often used at higher doses than recommended, showing a ‘persistent gap’ between clinical guidelines and real-world practice.

Writing in The Lancet Psychiatry, they concluded there is a need for new interventions that ‘prioritise safety and person-centred dementia care’ and support GPs with practical tools to manage patients.

The analysis of England primary care data from nearly 10,000 patients aged 60 to 85 between 2000 and 2023, found that in half of patients the first treatment lasted more than seven months, more than double the recommended maximum.

In addition, almost one in five (18%) patients were started on doses higher than the minimum effective amount.

Almost a third (29%) of that group remained on moderate or high doses throughout the first year, they reported.

More than half of those who discontinued their treatment then restarted treatment, the data showed, although usually for a shorter time than the previous prescription.

They found that one year after treatment initiation, 5,136 (78.3%) of 6,559 eligible individuals in the cohort remained on medication with 48.9% on low dose and 14.8% on moderate or high dose of haloperidol, olanzapine, quetiapine or risperidone; and 14.6% on other antipsychotics.

To address this issue, guidelines should offer more practical advice for GPs and carers, including how to manage cases where symptoms persist or return, the researchers said.

They also recommend integrating structured medication reviews into annual dementia check-ups and using decision-support tools to help clinicians assess whether continued treatment is necessary.

The Care Quality Commission and ICBs could use routine data to audit prescribing patterns and provide feedback to GP practices to help improve care, they added.

Author Dr Juan Carlos Bazo-Alvarez, a data scientist from the UCL Department of Primary Care and Population Health, said: ‘Looking at about two decades of primary care data, we found that many people with dementia remain on antipsychotics longer than guidance recommends, and that stopping and restarting treatment is common.

‘These insights from routine records can help clinicians make safer, more person-centred decisions about prescribing and reviewing medication.’

Professor Irene Petersen, senior author and professor of epidemiology and health informatics in the same team, said: ‘Our research highlights that there is a substantial gap between clinical guidelines and what is happening in practice. Perhaps it is time we re-evaluate the guidelines once again.’

A study from the University of Manchester last year found of antipsychotic medications in patients with dementia is linked with a much wider range of serious harms than previously thought.

Although there have been safety warnings on use of the antipsychotics from regulators about increased risk of stroke and death, the researchers found increased risks for pneumonia, venous thromboembolism, heart attack, heart failure, fracture, and acute kidney injury.