Antipsychotics for Alzheimer’s Disease

Reviewed by: HU Medical Review Board | Last reviewed: December 2023 | Last updated: February 2024

Psychiatric symptoms are common in Alzheimer’s disease. They are more likely as the disease progresses into later stages. As many as 9 out of 10 people with Alzheimer’s will have at least 1 psychiatric symptom.1,2

Psychiatric symptoms include:1,2

  • Aggression, anger, agitation, and paranoia
  • Wandering
  • Physical or verbal outbursts
  • Hallucinations (seeing, hearing, or feeling things that are not there)
  • Delusions (believing things that are not true)
  • Sleeplessness

People with Alzheimer's may also have behavioral symptoms, for example:1

  • Irritability
  • Anxiety
  • Depression

It is important to manage or treat psychiatric symptoms. This is because they lead to:2

  • More cognitive (thinking) problems
  • Earlier placement in memory care
  • Poor quality of life for the person and their caregivers

What are other causes of behavioral and psychiatric symptoms?

Health problems aside from Alzheimer's may manifest as behavioral and psychiatric symptoms. For example:1,2

  • Pain from an underlying infection and poor sleep contribute to agitation.
  • Depression may cause irritability and apathy.
  • Untreated vision and hearing problems can lead to more confusion.
  • Drug interactions are a common cause of worsening or unpredictable behavior.

The best approach to treating problem behavior is to identify and treat any underlying conditions first. Antipsychotic drugs will not relieve behaviors caused by untreated pain or drug interactions.2

Are antipsychotics safe?

Drugs of this type are often prescribed for people with Alzheimer’s-related psychiatric symptoms. This is particularly the case when psychiatric symptoms are leading to safety concerns or poor quality of life.2,3

But the US Food and Drug Administration (FDA) has only approved a few treatments for this use. These drugs should be prescribed with caution, particularly in the elderly. Their use is linked to early death, stroke, hallucinations, and relapse if the medicine is stopped.2,3

How do antipsychotics work?

Each type of antipsychotic drug works in different ways in the body. Many antipsychotics work in part by decreasing dopamine signaling in the brain. Antipsychotics do not cure psychiatric issues of Alzheimer’s. But they may relieve some of the symptoms.3

Examples of antipsychotics

There are generally 2 groups of antipsychotic medicines. These are typical (neuroleptic) drugs – which tend to be older medicines – and atypical, which are newer drugs.
Examples of typical antipsychotic drugs include:2

  • Acetophenazine (Tindal)
  • Chlorpromazine (Thorazine)
  • Haloperidol (Haldol®)
  • Thioridazine (Mellaril)
  • Trifluoperazine (Stelazine®)

Studies show no clear evidence that these drugs help people with dementia. One study found that haloperidol helps control aggression, but not other psychiatric symptoms.2

Examples of atypical antipsychotic drugs include:2,4

  • Brexpiprazole (Rexulti®)
  • Clozapine (Anafranil® and Clozaril®)
  • Olanzapine (Zyprexa)
  • Pimavanserin (Nuplazid®)
  • Quetiapine (Seroquel®)
  • Risperidone (Risperdal)
  • Ziprasidone (Geodon®)

Other drug types (classes) may be used to control some of the psychiatric symptoms of Alzheimer’s. These include:1,2

  • Antidementia drugs (cholinesterase inhibitors) to help with memory, thinking, and daily functioning
  • Antidepressants for depression, sleep problems, agitation, and irritability
  • Anxiolytics for anxiety and restlessness
  • Sleep aids for sleep disturbances and sundowning

What are the possible side effects of antipsychotics?

Side effects can vary depending on the specific drug taken. Some common side effects of antipsychotics and other behavioral drugs are:2

  • Heavy sedation
  • Worse memory and thinking skills, confusion
  • Repetitive facial movements (chewing, lip smacking, cheek puffing, grimacing)
  • Falls and fractures
  • Chest palpitations, chest pain, or other heart issues
  • Shortness of breath
  • Lightheadedness or fainting

These are not all the possible side effects of antipsychotics. Talk to your doctor about what to expect when taking antipsychotics. You also should call the doctor if your loved one has any changes that concern you when they take these drugs.

Other things to know

Most antipsychotics come with a boxed warning when prescribed for people with dementia. A boxed warning is the strictest warning from the FDA. Antipsychotic drugs have this warning because in people with Alzheimer’s these drugs are linked to higher rates of:2

  • Stroke
  • Heart attack
  • Death

Due to these risks, antipsychotics should only be prescribed for people with dementia if the symptoms:1

  • Are caused by mania or psychosis
  • Present a danger to the person or others
  • Cause significant, persistent distress or functional decline
  • Lead to difficulties receiving care

Before prescribing drugs for the psychiatric symptoms of Alzheimer’s, doctors will often suggest caregivers try:2

  • Distracting or redirecting the person
  • Structured routines
  • Maintaining a calm environment and demeanor
  • Pain management
  • Exercise

Before beginning treatment for Alzheimer’s, tell your doctor about all your health conditions and any other drugs, vitamins, or supplements you take. This includes over-the-counter drugs.

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