Antipsychotic medications are sometimes used to manage the behavioral and psychological symptoms of dementia, including Alzheimer’s disease. These symptoms can include agitation, aggression, hallucinations, and sleep problems, which can be very distressing for both the person with dementia and their caregivers. However, the safety of using antipsychotic drugs in people with Alzheimer’s disease is a complex and serious issue, with clear risks that must be carefully weighed against any potential benefits.
## What Are Antipsychotic Medications?
Antipsychotic medications, also called neuroleptics, are drugs originally developed to treat psychiatric conditions like schizophrenia. They work by affecting chemicals in the brain, such as dopamine and serotonin. There are two main types: typical (first-generation) and atypical (second-generation) antipsychotics. In dementia care, atypical antipsychotics like risperidone, olanzapine, quetiapine, and more recently, brexpiprazole, are most commonly used[1].
## Why Are Antipsychotics Used in Alzheimer’s Disease?
People with Alzheimer’s disease often experience changes in behavior and mood. These can include agitation, aggression, paranoia, and hallucinations. When these symptoms become severe and pose a risk to the person or others, doctors may consider prescribing an antipsychotic medication to help manage them[1][2]. The goal is to reduce distress and improve quality of life, but these drugs are not a cure for Alzheimer’s disease itself.
## What Do Guidelines Say?
Authoritative guidelines, such as those from the UK’s National Institute for Health and Care Excellence (NICE), state that antipsychotic medications should only be used for people with dementia when non-drug approaches have failed and the symptoms are severe, distressing, or pose a risk of harm[2][4]. Even then, antipsychotics should be used at the lowest effective dose for the shortest possible time—ideally just one to three months[2][4]. Regular reviews are recommended to check if the medication is still needed.
## What Are the Risks?
Antipsychotic medications carry significant risks, especially in older adults with dementia. Research shows that these drugs can increase the risk of stroke, pneumonia, worsening memory, and even death[1][2]. The risk of death is higher in elderly patients with dementia-related psychosis compared to those without dementia[1]. Side effects can also include dizziness, drowsiness, falls, urinary tract infections, and movement disorders[1].
A large UK study found that many people with dementia are prescribed antipsychotics for much longer than recommended—sometimes more than double the guideline maximum—and at higher doses than advised[2][4]. This increases the risk of harm without clear evidence of added benefit. The study also found that more than half of those who stopped antipsychotics later restarted them, highlighting ongoing challenges in managing these symptoms safely[4].
## Are There Any New Treatments?
Recently, the U.S. Food and Drug Administration (FDA) approved brexpiprazole specifically for the treatment of agitation associated with Alzheimer’s dementia[1]. Clinical trials showed that brexpiprazole can reduce agitation, but it still carries risks similar to other antipsychotics, including headache, insomnia, dizziness, and urinary tract infections[1]. It is important to note that even newer antipsychotics are not without risk in this population.
## What Should Patients and Families Know?
If a doctor suggests an antipsychotic for a loved one with Alzheimer’s disease, it is important to ask questions. Why is this medication being recommended? Are there non-drug options that could be tried first? What are the risks and benefits? How long will the medication be used, and how will its effectiveness and side effects be monitored?
Families should be aware that antipsychotics are not a first-line treatment for dementia-related behaviors. Non-drug approaches—such as creating a calm environment, establishing routines, and addressing unmet needs like pain or discomfort—should always be considered first[2]. If medication is needed, it should be used cautiously, at the lowest effective dose, and for the shortest time possible[2][4].
## The Big Picture
The use of antipsychotic medications in Alzheimer’s disease is a balancing act. While these drugs can help manage severe and distressing symptoms, they come with serious risks that must not be ignored[1][2][4]. Current practice often falls short of guidelines, with many patients receiving these medications for too long or at too high a dose[2][4]. Ongoing education for healthcare providers, better support for caregivers, and more research into safer alternatives are urgently needed.
Patients, families, and healthcare teams must work together to make informed decisions, always prioritizing safety and the well-being of the person with dementia.
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC12441263/
[2] https://www.ucl.ac.uk/news/2025/sep/uk-dementia-patients-may-be-taking-antipsychotics-too-long
[4] https://pubmed.ncbi.nlm.nih.gov/40967729/
