Delirium, Dementia, and Amnesia in Emergency Medicine Guidelines

Updated: Sep 19, 2018
  • Author: Richard D Shin, MD, FACEP; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
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Guidelines Summary

In 2016, the American Psychiatric Association released a practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. [19] The guideline is intended to apply to individuals with dementia in all settings of care as well as to care delivered by generalist and specialist clinicians.

The 15 statement guidelines are as follows:

  • Statement 1. Assess patients with dementia for the type, frequency, severity, pattern, and timing of symptoms. (1C)
  • Statement 2. Assess patients with dementia for pain and other potentially modifiable contributors to symptoms as well as for factors, such as the subtype of dementia, that may influence choices of treatment. (1C)

  • Statement 3. In patients with dementia with agitation or psychosis, assess response to treatment with a quantitative measure. (1C)

  • Statement 4. Develop a documented comprehensive treatment plan that includes appropriate person-centered nonpharmacological and pharmacological interventions, as indicated. (1C)

  • Statement 5. Only use nonemergency antipsychotic medication for the treatment of agitation or psychosis in patients with dementia when symptoms are severe, are dangerous, and/or cause significant distress to the patient. (1B)

  • Statement 6. Review the clinical response to nonpharmacological interventions prior to non-emergency use of an antipsychotic medication to treat agitation or psychosis in patients with dementia. (1C)

  • Statement 7. Before starting nonemergency treatment with an antipsychotic, assess the potential risks and benefits of the medication and discuss with the patient and the patient's caregiver/family. (1C)

  • Statement 8. If antipsychotic treatment is indicated, initiate treatment at a low dose and titrate up to the minimum effective dose as tolerated. (1B)

  • Statement 9. If a clinically significant side effect of antipsychotic treatment emerges, review the potential risks and benefits of antipsychotic medication to determine whether tapering and discontinuance of the medication are indicated. (1C)

  • Statement 10. If there is no clinically significant response after a 4-week trial of an adequate dose of an antipsychotic drug, taper or withdraw the medication. (1B)

  • Statement 11. In a patient who has shown a positive response to an antipsychotic, decisions about possible tapering of the medication should be made with input from the patient (if feasible) or surrogate decision maker, family, or other caregiver.  (1C)

  • Statement 12. In patients with dementia who show adequate response of behavioral/psychological symptoms to treatment with an antipsychotic drug, an attempt to taper and withdraw the drug should be made within 4 months of initiation, unless the patient experienced a recurrence of symptoms with prior attempts at tapering of antipsychotic medication. (1C)

  • Statement 13. In patients with dementia whose antipsychotic medication is being tapered, assessment of symptoms should occur at least monthly during the taper and for at least 4 months after medication discontinuation to identify signs of recurrence and trigger a reassessment of the benefits and risks of antipsychotic treatment. (1C)

  • Statement 14. In the absence of delirium, if nonemergency antipsychotic medication treatment is indicated, haloperidol should not be used as a first-line agent. (1B)

  • Statement 15. A long-acting injectable antipsychotic medication should not be utilized unless it is otherwise indicated for a co-occurring chronic psychotic disorder. (1B)