Antipsychotics: Are they worth it?


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Grace was in an anxiety tailspin. She was normally not very “redirect-able” as it was, but today seemed worse than normal. 

“Where’s my daughter!” she cried out. 

Grace was mobile…very mobile. She looked (and generally) spoke like a woman who did not have dementia. Grace was in the early-moderate stages of dementia, which is really the hardest place to be for someone with a cognitive impairment. People in early and early-moderate stages are usually really hard to redirect and calm down. Oftentimes, they know that something is wrong with them. 

You’ll often hear me say, “Dementia gives people gifts.” By this I mean, in a moderate stage of dementia, most people do not realize that they have a problem. By that fully-moderate or late-moderate stage, most people with dementia are actually quite pleasant, because they often live in a happier world than we do.

But, Grace wasn’t there yet. And she was already a person with a history of anxiety, so dementia made it even worse. Her short-term memory was incredibly poor (nearly minute to minute) so she could not remember that I had just told her that her daughter was on the way.

This happened a lot, and it was upsetting for everyone, especially Grace and her daughter. I felt really sad for Grace, and as a woman with anxiety myself, I can tell you that it was particularly hard to watch her suffer.

A lot of people will tell you, “Never use antipsychotics on older adults and people with dementia.” The reason that they are telling you that is because antipsychotics have what’s called a “black box warning” on them. This means that they are contraindicated (shouldn’t be used, or be used sparingly) with people who have dementia. 

Here’s the problem: some people really need them. Grace was one of these people.

I consider myself to be the best of the best at redirection and embracing the reality of people with dementia. I could not redirect Grace for more than 10-15 minutes. Ever. 

We had tried multiple medications for her: anti-anxiety, anti-depression, this, that and the other. 

The only thing that seemed to have any positive effect on her was an antipsychotic. That was it.

Do antipsychotics work for everyone? No. Should they be used as a last-ditch effort in dementia care? Absolutely. You need to work through all the other problems first. You need to be a dementia detective and see if you can solve someone’s problems without medication. 

But these medications exist for a reason. The people who say, “Never use antipsychotics on anyone!” have never worked in full-time dementia care. I remember reading about medications in college and thinking, “Oh, we should never use these!” but as I started working in dementia care, I realized that I hadn’t had the experience to back up my education. 

Some people absolutely need antipsychotics to live a happy, healthy life.

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Rachael Wonderlin is an internationally-recognized dementia care expert and consultant. She has a Master’s in Gerontology and is the author of three published books with Johns Hopkins University Press. Rachael owns Dementia By Day, a dementia care consulting and education company.

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