Memory Digest

Antipsychotics and Dementia: Risks

Antipsychotic drugs are sometimes used for severe agitation, aggression or hallucinations in dementia, but they carry an FDA boxed warning for increased risk of death; learn the risks, when they may be appropriate, alternatives, and questions to ask.

Last reviewed: October 2026

When someone with dementia becomes very agitated, aggressive, or frightened by things that aren't there, families and care staff may feel desperate for something that works quickly. Antipsychotic medicines—drugs originally developed for conditions like schizophrenia—are sometimes prescribed. They can help in certain situations, but they also carry serious risks for older adults with dementia.

This article explains those risks so you can have an informed conversation with the doctor. It is not a guide to starting or stopping any medicine. Never stop an antipsychotic suddenly without medical advice.

Which drugs are antipsychotics?

Common examples include:

• Risperidone (Risperdal)
• Quetiapine (Seroquel)
• Olanzapine (Zyprexa)
• Aripiprazole (Abilify)
• Haloperidol (Haldol)
• Brexpiprazole (Rexulti)

Most of these are prescribed "off-label" for dementia, meaning they are not FDA-approved for that use.

The FDA boxed warning

The Alzheimer's Association explains that research has linked antipsychotics to an increased risk of stroke and death in older adults with dementia. The FDA requires these drugs to carry a "black box" warning—its strongest kind—about this risk, along with a reminder that they are not approved to treat dementia-related psychosis.

What a large recent study found

A 2024 study in The BMJ followed more than 173,000 adults with dementia in England, comparing about 35,000 who started an antipsychotic with similar people who didn't. Antipsychotic use was linked to higher risks of:

• Pneumonia (about twice the risk during current use)
• Acute kidney injury
• Blood clots in the veins
• Stroke
• Broken bones (from falls)
• Heart attack and heart failure

Risks were highest soon after starting the drug. For example, in the first 90 days, about 4.5% of new users developed pneumonia, compared with about 1.5% of non-users. The authors concluded the range of harms was wider than previously recognized.

The American Geriatrics Society's Beers Criteria advise avoiding antipsychotics for behavioral problems of dementia unless non-drug options have failed or aren't possible and the person is a danger to themselves or others.

A special warning for Lewy body dementia

People with Lewy Body Dementia or Parkinson's Disease Dementia can have severe, sometimes life-threatening reactions to some antipsychotics, including sudden worsening of movement, confusion and alertness. If Lewy body disease is possible, make sure every doctor knows before any antipsychotic is considered.

When they may be appropriate

According to the Alzheimer's Association, people with dementia should use antipsychotics only when:

• Symptoms are due to mania or psychosis
• Symptoms present a danger to the person or others
• The person has inconsolable or persistent distress, a significant decline in function, or great difficulty receiving needed care

The Association adds that antipsychotics should not be used to sedate or restrain people with dementia, and that the lowest dose should be used for the shortest time possible, with careful monitoring.

FDA-approved options for agitation

Two medicines now have FDA approval specifically for agitation associated with dementia due to Alzheimer's disease:

• Brexpiprazole (Rexulti), an antipsychotic approved in 2023. It carries the same boxed warning about increased death risk in older adults with dementia-related psychosis.
• Dextromethorphan-bupropion (Auvelity), approved in April 2026, the first non-antipsychotic drug approved for this use. It combines a cough-suppressant ingredient and an antidepressant. The FDA lists side effects including dizziness, headache, diarrhea and drowsiness, and warns it can cause seizures and raise blood pressure.

Approval doesn't mean a drug is right for everyone. Ask how benefits and risks apply to your loved one.

Try non-drug approaches first

Most experts agree that behavior changes in dementia are often a form of communication—a sign of pain, fear, boredom, hunger, an infection, overstimulation or unmet needs. Steps that often help:

• Look for physical causes: pain, constipation, urinary infection, poor sleep, hearing or vision problems, or a new medicine (see Delirium vs. Dementia)
• Change the environment: reduce noise and clutter, improve lighting, keep routines predictable
• Change the approach: stay calm, reassure, redirect, avoid arguing (see Communicating with Someone with Dementia)
• Add meaningful activity: music, walks, simple tasks (see Music and Art Therapy)

Our article on Managing Challenging Behaviors covers these strategies in detail.

Questions to ask the doctor

1. What symptom is this medicine meant to treat, and how will we know if it's working?
2. Have we ruled out pain, infection and other medical causes?
3. What non-drug approaches should we try alongside it?
4. What are the specific risks for my loved one?
5. What dose are we starting with, and for how long?
6. When will we review whether to lower or stop it?
7. Could this person have Lewy body disease?

Reviewing and reducing

Guidelines encourage regular review of antipsychotic use, with attempts to taper when symptoms are stable. Research has found that many people with dementia can reduce or stop these drugs without their symptoms returning, but this must be done gradually with medical supervision. In nursing homes, ask how often the care team reviews these prescriptions.

Where to get help

• Alzheimer's Association 24/7 Helpline: 800-272-3900
• Eldercare Locator: 800-677-1116

See also Treating Behavioral Symptoms and Agitation and Aggression.

Sources

1. Alzheimer's Association: Treatments for Behavior
2. Mok PLH et al. Multiple adverse outcomes associated with antipsychotic use in people with dementia: population based matched cohort study. BMJ, 2024
3. U.S. Food and Drug Administration: FDA Approves First Drug to Treat Agitation Symptoms Associated with Dementia due to Alzheimer's Disease (2023)
4. U.S. Food and Drug Administration: FDA Approves First Non-Antipsychotic Drug to Treat Agitation Associated with Dementia (2026)
5. American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (via PubMed Central)

Not medical advice. This article is general information, not a diagnosis or treatment plan for any individual. Talk with a doctor about your situation.

Related articles

• Managing Challenging Behaviors
• Agitation and Aggression
• Hallucinations and Delusions
• Lewy Body Dementia
• Medications That Can Affect Memory