How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?

Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients.

If nothing else works for a behavioral problem, you have to use an antipsychotic.

Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment will be needed. Keep the dose as low as you can.

Check cardiac rhythm, QTC, and consider getting clearance from a cardiologist.

I start by having a frank discussion with the patient and family, discussing the low but real risk, and discuss that other options have been tried. I ask the patient about their priorities, for example if dignity is more important right now than potential risk of stroke or even death, is that acceptable. Then I discuss a monitored trial.