The authors recommend evaluating environmental factors (such as negative caregiver interactions) that might be contributing to the patient’s behavior. The clinician should also ascertain which nonpharmacologic strategies have previously been attempted. An array of interventions (e.g., reassurance, redirection, increased structure, and activities) can be helpful in addressing these symptoms4,5 and should be tried before the initiation of antipsychotic therapy. Lastly, it may be advisable to explore whether a trial of an alternative psychotropic class (e.g., an antidepressant) may be preferable.

If a decision has been made to initiate therapy with antipsychotics, a good dictum to employ is “start low, go slow.” Starting with a low dose and titrating slowly can minimize the risk of sedation and parkinsonism. The authors recommend target daily dose ranges of 0.25mg–1mg of risperidone, 2.5mg–7.5mg of olanzapine, 12.5mg–150mg of quetiapine, and 5mg–10mg of aripiprazole.

The authors advise that, given the potential metabolic effects of atypical antipsychotics, a chemistry profile, lipid profile, fasting blood glucose level, and weight should be obtained at baseline. Follow-up evaluations should be conducted at three months, six months, and every six months thereafter. Additionally, they recommend a baseline electrocardiogram (ECG), due to the potential of most atypical antipsychotics to increase QTc, and they advise caution before initiating treatment in patients with a prior cardiovascular history or baseline QTc abnormalities.

The decision of whether to increase the dose or switch medications is complex, as many patients have only partial remission of symptoms even under the best of circumstances, so increasing the dose may be ineffective or even counterproductive.

The authors emphasize that these decisions must be made with informed consent on the part of the patient (if possible) or the surrogate decision-maker. Risks and anticipated benefits of antipsychotic treatment should be discussed openly, including the risk of stroke and mortality. Alternative options should be explored. Patients and caregivers should be educated about side effects, such as falls, parkinsonism, and sedation.

The authors summarize their approach by saying, “Until better treatment options become available, atypical antipsychotics continue to have an important, albeit limited, role in dementia care. Safety risks can be minimized through careful selection of appropriate patterns for treatment, education of patients and surrogate decision makers, and close monitoring with the understanding that for many patients, short-term, treatment is sufficient.”

RESOURCES
1. Sultzer DL, Davis SM, Tariot PN, et al. Clinical symptom responses to atypical antipsychotic medications in Alzheimer’s disease: Phase 1 outcomes from the CATIE-AD effectiveness trial. Am J Psychiatry. 2008;165:844–854.

2. Steinberg M, Lyketsos CG. Atypical antipsychotic use in patients with dementia: Managing safety concerns. Am J Psychiatry. 2012;169:900–906.

3. American Geriatric Society American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616–31.

4. Teri L, Logsdon RG. Assessment and management of behavioral disturbances in Alzheimer disease. Compr Ther. 2000;26:169–175.

5. Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia: A review, summary, and critique. Am J Geriatr Psychiatry. 2001;9:361–381.