Are Antipsychotic Medications Safe for Older Adults With Dementia?

If someone you care for is living with dementia, there may come a time when one of their doctors suggests an antipsychotic medication. You may wonder why it is being recommended, what it could help with, and whether it makes sense for your loved one. 

As with many medical decisions, there isn’t a simple answer. Antipsychotics can reduce severe or distressing symptoms for some people with dementia, but they also carry risks worth considering. 

As Hebrew SeniorLife’s medical director of psychiatry, I help patients with dementia and their families navigate medication-related decisions at the licensed long-term chronic care hospitals at Hebrew Rehabilitation Center in Boston and Hebrew Rehabilitation Center at NewBridge on the Charles. 

Caregivers and families can benefit from understanding why antipsychotic medications might be recommended to someone with dementia and what questions to ask if they are. 

What are antipsychotic medications?

Antipsychotic medications were originally developed to treat psychosis, which affects how someone experiences and interprets what is happening around them. Symptoms of psychosis include hallucinations, delusions, and severely disorganized thinking.  

People living with dementia sometimes develop psychosis related to their illness. For example, someone with dementia experiencing a delusion may think that their caregiver is trying to hurt them.

Despite their name, antipsychotics are not only used for the treatment of psychosis. Physicians also sometimes prescribe them for other mental health conditions (e.g, depression, bipolar disorder, and anxiety) and dementia-related agitation. In fact, the U.S. Food and Drug Administration approved the first medication to treat agitation associated with dementia due to Alzheimer’s disease in 2023. 

How antipsychotics fit into dementia care  

There are times when a doctor may recommend an antipsychotic for someone with dementia. These medications can help relieve severe distress, improve quality of life, or allow someone to receive essential care.

For example, a person may experience hallucinations or delusions that leave them frightened or upset. Someone who believes their caregivers are trying to poison them may refuse food, medication, or other necessary care. Antipsychotics could also be considered if severe agitation or aggression puts someone or others at risk of harm.

However, these medications should not be used simply to make a patient easier to care for. Evidence has shown that long-term care settings have historically overprescribed antipsychotics, including a 2026 federal report that identified cases where some nursing homes used antipsychotics to make it easier for staff to take care of their residents. That is not an appropriate reason to prescribe them.

Antipsychotics also do not help with every behavior that happens to be dementia-related. Wandering may primarily respond to antipsychotics by heavily sedating someone, limiting their freedom and independence. A more compassionate way to manage wandering is to provide an environment where people can move around safely. Hebrew Rehabilitation Center offers secure units that support people with all stages of dementia.

A thoughtful, person-centered care approach helps prevent facilities from overprescribing antipsychotic medications for patients who would not benefit from them.

Understanding a new behavior before considering medication

Ruling out underlying medical conditions

Behavioral symptoms are common in people living with dementia. That said, physicians should not assume that every new behavior is caused by dementia. A sudden change in how someone is acting could be related to an acute medical issue, such as delirium, infection, dehydration, or a medication side effect.

In these cases, treating the underlying acute condition can resolve the new behavior. The first step when a new behavior emerges should always be a medical evaluation.  

Considering what someone’s behavior is communicating 

Agitation or resistance to care in people with dementia can sometimes be the only way a person can communicate fear, discomfort, confusion, or another unmet need. There can be ways to make people feel heard without medication.

For example, medical providers can use an approach called “retreat and return” when a patient is acting resistant to receiving care. That means walking away when the person is not open to care and trying again later, when they may feel more comfortable. Providers may also consider non-antipsychotic medications that can ease symptoms, which are often worth trying first.

Adapting patient care through habilitation  

At Hebrew Rehabilitation Center, staff use a care approach called habilitation. While rehabilitation aims to help someone regain abilities, habilitation focuses on adapting care to where someone is today. It involves learning about who they are, understanding their routines and preferences, and considering what they may be trying to communicate with their behavior.

Imagine that a person with dementia at a long-term care facility begins waking up at 4 a.m., getting dressed, asking for breakfast, and wandering. If they can’t explain why verbally, this new behavior may initially seem confusing to staff members. Then, a conversation with that patient’s family reveals that the person worked as a delivery driver and began their day that early for decades.

In the context of that person’s life, this behavior makes sense. Rather than trying to change or suppress it with medication, the care team can offer breakfast, allow the patient to shower, and help them start their day. By understanding the motivation behind their behavior, their care team can meet their needs without unnecessarily prescribing medication.  

Weighing the benefits and risks of antipsychotics 

Even when an antipsychotic may be helpful, the decision to use one should be considered carefully.  

In studies cited by the FDA, people with dementia-related psychosis who received an antipsychotic were around 1.6 to 1.7 times more likely to die than those who received a placebo. While mortality risk is still low overall, those findings prompted the FDA to require its strongest safety warning — known as a “black box” warning — for consideration when prescribing these medications to older adults with dementia-related psychosis.

Antipsychotics can also cause side effects such as sleepiness, oversedation, and tremors or other symptoms that resemble Parkinson’s disease.  

These risks also increase with dosage. At Hebrew Rehabilitation Center, we begin with the lowest appropriate dose and increase it slowly, only if necessary. We then continue to monitor whether the medication is helping, causing adverse effects, and whether the dose can be safely reduced.

These risks are important to consider, but so is the very real distress that psychosis and agitation can cause. For some people, an antipsychotic can ease severe symptoms and make life more comfortable, and not everyone will experience side effects. The decision ultimately comes down to whether those potential benefits make sense for your loved one, which is a conversation you should have with their physician. 

Questions to ask when a provider recommends an antipsychotic 

If a clinician treating your loved one recommends an antipsychotic medication, asking questions can help you feel more informed and comfortable with the decision. You might ask: 

• What symptom are you hoping to treat? 
• What nonmedication approaches have you tried? 
• What benefits should we expect? 
• What adverse effects will you be monitoring? 
• When will you reassess this medication?

How your physician responds can help you understand whether there is a clear purpose and a thoughtful plan behind a suggested antipsychotic medication. 

Find person-centered dementia care at Hebrew Rehabilitation Center 

At Hebrew Rehabilitation Center, our interdisciplinary teams provide person-centered care for older adults with complex and chronic medical needs, including dementia. We take the time to learn about each patient’s history, routines, preferences, and goals so we can shape their care around who they are, including medication management. 

Learn more about our approach to long-term chronic care and how to begin the admissions process.