In recent years, there has been a notable increase in the prescription of antipsychotic medications among older adults, particularly those with dementia. This trend raises concerns about the implications of prescribing potentially life-threatening sedatives in this vulnerable population.

The Growing Prescription Rates

Research conducted by Rutgers and Columbia University, published in JAMA Psychiatry, highlights a staggering increase of nearly 52% in the annual rate of antipsychotic prescriptions for adults aged 65 and older between 2015 and 2024. Notably, long-term use (defined as prescriptions lasting at least 120 days per year) rose by 65%. This upward trend is most pronounced among adults aged 75 and older, where use increased from 3.42 to 5.12 per 100 individuals during the study period.

Serious Risks Associated with Antipsychotics

Despite their increasing use, antipsychotic medications have limited effectiveness for treating dementia-related symptoms, which include agitation, wandering, and aggressive behaviors. Furthermore, these medications come with a black-box warning indicating an increased risk of death among elderly patients. The potential risks associated with antipsychotic use are concerning and include:

  • Increased risk of fractures
  • Cerebrovascular events
  • Pulmonary embolism
  • Higher mortality rates

Factors Contributing to Increased Prescriptions

Antipsychotics are intended for patients with severe psychiatric conditions such as schizophrenia or bipolar disorder, yet these conditions are not common among the elderly. Stephen Crystal, a co-author of the study, emphasizes that the rise in prescriptions is likely not explained by underlying psychiatric illnesses.

Behavioral and psychological symptoms associated with dementia are often managed with these medications. As Crystal points out, the medications are sometimes used to alleviate distressing behaviors that disrupt care facilities and burden caregivers. While they may reduce behaviors such as wandering and shouting, the sedating effects often lead to increased fall risks and diminished physical activity in frail elderly patients.

Shifts in Prescribing Practices

The study also reveals a troubling trend: the involvement of psychiatrists in managing antipsychotic prescriptions has declined significantly. The percentage of patients receiving an antipsychotic prescription while also being seen by a psychiatrist decreased from 30% in 2015 to 20% in 2024. Conversely, the number of prescriptions filled directly at long-term care facilities climbed from 14% to 21%. This shift raises questions regarding the adequacy of care being provided, as the optimal management of dementia-related behaviors should involve thorough assessments, including evaluation of alternative treatment options.

Alternative Approaches and Future Directions

Despite the pervasive reliance on antipsychotic medications, there is potential for developing nonpharmacological interventions that can address the underlying issues contributing to behavioral disturbances in dementia patients. These alternatives require appropriate training and resources but could lead to better patient outcomes. The study authors advocate for:

  • Implementation of nonpharmacological interventions to address challenging behaviors.
  • Enhanced training for staff on how to manage symptoms effectively without resorting to medication.
  • Regular reassessment of antipsychotic prescriptions to ensure that they are still necessary.
“These are high-stakes decisions,” said Mark Olfson, the study's lead author. It is critical for healthcare providers to evaluate what problems the medications are meant to address and to have a plan for tapering off the medications once the immediate crisis has been resolved.

Families receiving new prescriptions for antipsychotics should feel empowered to question the rationale behind their use. Understanding the potential risks and benefits of these medications is essential in making informed decisions about senior care.

Conclusion

The upward trend in antipsychotic prescription rates among older adults warrants careful attention. While these medications may be used to manage distressing symptoms of dementia, their associated risks highlight the need for improved management strategies that prioritize patient safety and wellbeing.

References

Olfson, M., et al. (2025). Antipsychotic Medication Use by Older Adults, JAMA Psychiatry.