This study showed that many people with dementia who lived in specialized care units were prescribed antipsychotic drugs for long periods. It seems that in most cases the doses were probably not regularly adjusted; a majority of the people appeared to be on stable doses for six months or possibly longer. There were also few people in our study who had been prescribed the drugs in agreement with current recommendations concerning dosage and drug choice. The study showed that people who exhibited aggressive behavior, or passiveness, or had a higher cognitive score, were at increased risk of being prescribed antipsychotics. Those who received antipsychotics were also significantly younger. We found no difference between men and women concerning antipsychotic drug use.
Furthermore, the use of more than one psychotropic drug seemed to be common, 72/344 had anxiolytics/ hypnotics/sedatives and an antipsychotic drug prescribed simultaneously and 73/344 had antidepressants and an antipsychotic drug prescribed simultaneously. In addition, 14 persons had more than one antipsychotic drug prescribed.
The present results are in accordance with previous studies. One study found that people received psychotropic drugs over at least one year despite uncertainty about symptom improvement and another study showed that most antipsychotic prescriptions remained unchanged over a six-month period [17, 18]. In the present study, 63/111 (57%) received exactly the same antipsychotic dose after six months. The high prevalence of long-term use is not in line with current recommendations which emphasize that treatment should be time-limited and regularly reviewed . Selbæk et al also demonstrated that most symptoms show an intermittent course which does not support long-term treatment with antipsychotics . O’Connor et al discuss the fact that the person’s symptoms are classified as present when in reality they occur only occasionally . These findings stress the importance of reviewing antipsychotic use regularly to ensure that the indication remains. One study also showed that dementia persons’ symptoms remain stable when they are withdrawn from first generation antipsychotics, and another study found that people actually improved when second generation antipsychotics were withdrawn [25, 26].
Furthermore, the indications that were given for the prescriptions in our study were not in line with the recommendations. By far the most common indication in this study was “treatment of disturbed and restless behavior/sedative”, and this is not an approved indication, according to the guidelines. Some indications were doubtful and in many cases were missing. However, these results should be interpreted with caution since the indications often overlap and the way of expression might differ between physicians. The choice of antipsychotic drugs among prescribers in this study was somewhat surprising considering that the second generation antipsychotics risperidone and olanzapine seem to have the best evidence-base for effectiveness, compared to placebo for physical aggression, agitation and psychosis [27, 28]. Risperidone and haloperidol were the most commonly used antipsychotics in our study, which is to be expected. Haloperidol has little anticholinergic activity and was by many considered the most preferable antipsychotic to people with dementia before the introduction of the second generation antipsychotics. An established treatment tradition might possibly have delayed the switch to second generation drugs and explain why many old people with dementia were still treated with haloperidol in 2006. Haloperidol has some efficacy against behavioral problems in higher doses, but its use is limited by side-effects . Risperidone on the other hand is a well-tolerated alternative among people with dementia in lower doses  and is, as stated above, the only antipsychotic drug that is labeled for use in BPSD in Sweden. The proportion of people with antipsychotics treated with second generation drugs will probably continue to increase .
A more unexpected finding was the fact that these two drugs did not account for a larger share of the antipsychotic prescriptions. Many older first generation antipsychotics and also some of the newest second generation antipsychotics were used to treat BPSD in this patient group. The reason prescribing physicians deviated from current guidelines is unclear. This study was conducted in 2005 and 2006, i.e. 2-3 years before the guideline was issued. Possibly, the prescription may have changed due to new recommendations, however, we still find it relevant to compare the treatment with what is now considered to be appropriate medication.
However, there are other possibilities for treating BPSD in persons with dementia. Primarily, non-pharmacological approaches are recommended, such as investigation /survey of symptoms, possible causes and triggering moments. It is also important to review current pharmacological treatment and consider discontinuation of drugs with potentially adverse effects on the central nervous system and finally, to optimize the care environment and treatment [1, 31]. For example, it has been shown that music, physical exercise and recreation might have some effect considering psychological symptoms in people with dementia . When it comes to pharmacological treatment, memantine, cholinesterase inhibitors and SSRI have shown positive efficacy in various studies [33–39]. Among anti-dementia drugs, memantine appears to reduce specific problems such as agitation and irritability . Concerning cholinesterase inhibitors, one meta-analysis showed that rivastigmine had positive effects on nonpsychotic and psychotic symptoms associated with Alzheimer’s disease . Among antidepressants, citalopram has for example showed significant efficacy against behavioral disturbances in individuals with dementia [36, 37], and sertraline has showed efficacy against aggressive behavior . Selective serotonin reuptake inhibitors are also recommended as first line treatment for irritability, agitation and anxiety among people with dementia .
The association found between antipsychotics and aggressive behavior, as well as the association between antipsychotic use and lower age, confirms the results of an earlier study . The increased risk of receiving antipsychotic treatment among people with aggressive behavior might be expected since this is one of the approved indications for antipsychotics. We also found an association between use of antipsychotics and a higher cognitive score. It has been shown that the prevalence of the behaviors and symptoms decline in those with severe cognitive impairment, and this might possibly lead to less use of antipsychotics . There was also an association between passiveness and use of antipsychotics in the present study. It has been shown that passiveness increases almost linearly with the severity of cognitive impairment . It can be difficult to know what is cause and what is effect, but the passiveness shown among those who use antipsychotic drugs might also, in some cases, be a side-effect of the antipsychotics.
This study did not show any difference in mortality between those who received antipsychotics at the start of the study and those who did not. Several studies have reported an increased mortality among people prescribed antipsychotics, [13, 14] while other studies have not - for example one study that found no association between antipsychotics and cerebrovascular events compared to benzodiazepines . A selection effect, where the healthier persons were possibly prescribed antipsychotics more frequently, might have contributed to our results considering mortality and antipsychotics. We did not know the length of exposure to antipsychotics, only that a person was treated with an antipsychotic drug at the start of the study and this have possibly influenced the results. Also, in this study we lacked information about the prevalence of cerebrovascular diseases and other co-morbidities that might have impacted on mortality.
In this study we have been able to describe in detail long-term use of antipsychotics among people with dementia. The registration of drugs and doses in the present study was of high quality. We can also assume that compliance was high since the vast majority of patients used an automated dose dispensing system.
The study also has some methodological limitations. The selection of specialized care units was not random but based on the prevalence of physical restraint use. It could be that people in these homes have severe problems with BPSD and, therefore, receive long-term treatment to a greater extent. In the physical restraint study  there was no difference in antipsychotic use within groups or between groups at baseline and after six months, but we have not been able to compare data with non-selected units since we do not have that information. However, the proportion of those who were on antipsychotic drugs does not appear to differ from those found in other studies . We believe that this does not affect the main results of the study, but it should be borne in mind when interpreting the results.
Data were registered at the start of the study and six months later, but what happened between those times is not known, except for mortality. We do not know the duration of antipsychotic treatment at the time of recruitment into the study, and we also do not know if any attempts of dose reduction or attempts of non-pharmacological treatment of BPSD have been made. Further, we do not know the background or other diseases of the participants, and we lack information about adverse effects of antipsychotics e.g. extrapyramidal effects or falls.
In our study, there could possibly have been reasons other than BPSD for prescribing antipsychotics. Some people might have schizophrenia or other chronic psychotic illnesses where recommendations about dose and substance differ from recommendations among people with dementia. This might, to some extent, explain the use of other antipsychotic drugs or higher doses.
Still, the reason for prescribing antipsychotics is probably related to BPSD in the vast majority of cases, among old people with dementia living in specialized care units.