"The Lesser of two Evils" Versus "Medicines not Smarties": Constructing Antipsychotics in Dementia

Dilbagh Gill, MPharm; Saleh Almutairi, PhD, MSc, BSc; Parastou Donyai, PhD, BPharm, BSc


Gerontologist. 2019;59(3):570-579. 

In This Article

Abstract and Introduction


Background and Objectives: Because antipsychotics are associated with an increased risk of morbidity and mortality, they should only be prescribed in dementia in limited circumstances. But antipsychotics are prescribed to a large proportion of residents in formal care settings despite guidance and warnings to the contrary, justifying a study into how professionals define and in turn create realities about antipsychotic usage in dementia.

Research Design and Methods: Twenty-eight professionals with a role in the care and management of patients with dementia in care homes were recruited and interviewed in this qualitative study. A gap in the literature about the social construction of antipsychotics in dementia prompted the use of critical discourse analysis methodology.

Results: Antipsychotics were portrayed in 2 distinct ways; as "the lesser of two evils' they were conceptualized as the less harmful or unpleasant of 2 bad choices and as "medicines not Smarties" (a brand of sweets/candy) they were conceptualized as prescribed too frequently and indiscriminately. The first resource could be used to defend the prescribing of antipsychotics and uphold the prescribers' privilege to do so whereas the second enabled the speaker to reject their own wilful involvement in overprescribing.

Discussion and Implications: When prescribers draw on "the lesser of two evils" paradigm to sanction the overprescribing of antipsychotics, implicit assumptions about these medications as being the best of bad choices should be recognized and challenged. Future studies should target specific normative beliefs about antipsychotic prescribing consequences, to change the lexicon of common knowledge which perpetuates bad practice.


There was an estimated 46.8 million people living with dementia worldwide in 2015 (Alzheimer's Disease International, 2015). The prevalence of dementia in people aged 60 and over is 6.9% in Western Europe and 6.4% in North America (Alzheimer's Disease International, 2015). Dementia is characterized by loss of memory, mental agility, understanding, speech and judgment. However, dementia can also lead eventually to noncognitive symptoms impacting on temperament and social behaviors (Cerejeira, Lagarto, & Mukaetova-Ladinska, 2012). It can be challenging for carers and others when a person with dementia experiences agitation, aggression, irritability and outward expressions of hostility (Leggett, Zarit, Taylor, & Galvin, 2011; Ory, Hoffman, Yee, Tennstedt, & Schulz, 1999; Tremont, 2011; Zimmerman et al., 2005). In specific and limited circumstances, antipsychotic medications are permitted to be prescribed to treat patients whose noncognitive symptoms are severe and become unmanageable. Although effective in controlling some of the challenging behaviors of dementia, antipsychotic medications can result in a number of common side-effects including sleep disturbance, blood pressure changes, anticholinergic effects (e.g., dry mouth, urinary incontinence, constipation, blurred vision), Parkinsonism, and weight gain. Generally speaking, atypical antipsychotics such as risperidone, olanzapine, and quetiapine are preferred to older (first generation) antipsychotics but in the United Kingdom, risperidone is the only antipsychotic licensed for short-term use in dementia. The use of atypical antipsychotics in dementia is controversial because of an association with an increased risk of morbidity as well as mortality (Ballard, Creese, Corbett, & Aarsland, 2011; Huybrechts et al., 2012; Schneider, Dagerman, & Insel, 2005). For this reason, in the United States, no antipsychotic is approved for the treatment of dementia-related psychosis and since 2008 a "Black Box Warning" must appear on package inserts of both atypical and first-generation antipsychotics to warn about the increased risk of mortality in elderly patients with dementia-related psychosis (Food and Drug Administration, 2008).

There have been longstanding warnings about the use of antipsychotic medications in dementia by medicines regulators in the United Kingdom, Europe, and the United States (European Medicines Agency, 2008; Food and Drug Administration, 2008; Medicines & Healthcare Products Regulatory Agency, 2005). In the United Kingdom, guidelines advocate a range of non-pharmacological interventions for managing the noncognitive and behavioral symptoms of dementia, supporting first-line medication use only where patients are severely distressed or there is an immediate risk of harm, and only on meeting some specific requirements (National Institute for Health and Care Excellence, 2006). In the United States too, the American Alzheimer's Association and the American Geriatric Society recommend the use of antipsychotics only where non-pharmacological options have failed and there is a threat to life (Alzheimer's Association, 2011; Samuel, 2015). The American Psychiatric Association recommends the nonemergency use of antipsychotics only where symptoms are severe, dangerous and/or cause significant patient distress and again on meeting a number of other prerequisites (Reus et al., 2016).

Although the use of antipsychotic medications might be warranted in limited circumstances, in the United Kingdom it is estimated that only 20% of 180,000 patients with dementia prescribed an antipsychotic each year may actually benefit from them (Banerjee, 2009). A landmark report investigating the use of antipsychotics for people with dementia in the National Health Service in England found that inappropriate use could be resulting in an additional 1,620 cerebrovascular events and another 1,800 deaths each year (Banerjee, 2009)—this led to the launch of the national dementia strategy in England (Department of Health, 2009). The inappropriate prescribing of antipsychotic medications in dementia is also evidenced in the United States (Samuel, 2015) where in 2012 the Centers for Medicare and Medicaid Services, part of the U.S. Department of Health and Human Services, also launched a partnership programme to improve comprehensive dementia care and reduce antipsychotic prescribing (Centers for Medicare & Medicaid Services, 2017).

The prescribing and use of antipsychotics is particularly high in formal institutions providing care for older people. In the United States formal care institutions include community and Veterans Administration (VA) nursing homes and in the United Kingdom, nursing homes, residential homes (providing personal care only) or a combination of both. Although in the United States antipsychotics are thought to be prescribed to approximately 20%–35% of residents in formal care settings (Chen et al., 2010; Gellad et al., 2012; Kamble, Sherer, Chen, & Aparasu, 2010), this figure is around 20%–25% for residents in U.K. care homes (Department of Health, 2009; Maguire, Hughes, Cardwell, & O'Reilly, 2013) A qualitative study with old age psychiatrists in England uncovered a range of views about psychotropic prescribing in dementia (Wood-Mitchell, James, Waterworth, Swann, & Ballard, 2008). Psychiatrists thought there were pressures on them to prescribe, felt societal and systemic influences maintained high prescribing rates, guidelines were not implementable, and care homes not designed and trained to deal with problematic behaviors (Wood-Mitchell et al., 2008).

When the views of nursing staff were explored, the results were dichotomized as benefits of, versus barriers to, reducing antipsychotic use (Simmons et al., 2017). What is particularly noteworthy is that the benefits of reducing antipsychotic usage (e.g., improvement in patients' quality of life, families' sense of satisfaction and reduction in falls) were couched mainly in relation to the detrimental effects of antipsychotics whereas the barriers (e.g., resistance by families, symptom worsening or returning, lack of alternatives) were couched in relation to the usefulness of antipsychotics. There has been little work to date to examine health professionals' construction of antipsychotics in tackling the behavioral symptoms of dementia from a discourse analytic perspective. This is despite literature on the social construction of dementia itself (Bartlett, Windemuth-Wolfson, Oliver, & Dening, 2017; McInerney, 2017; McParland, Kelly, & Innes, 2017; Peel, 2013; Zeilig, 2014). This paper uses the definition of discourse analysis developed by Potter & Wetherell (1987) which focuses on talk as social practice, and on the resources that are drawn upon to enable those practices. Under this definition, discourse analysis focuses on how language is used to create reality, within a social constructionist epistemology which views knowledge as socially contingent and fluid—further explained in the Research Design and Methods section. Understanding how people conceptualize antipsychotics is significant because it allows for negative or misleading constructions to be uncovered and questioned rather than blindly accepted.

Prosser (2010), taking a discourse analytic approach, analyzed media coverage of prescribed medicines finding two competing discourses as "marvellous medicines" and "dangerous drugs." The "good news stories" presented the beneficial properties of medicines with use of powerful adjectives ("super-effective, wonder drug, brainwave pill, miracle cure"). The "adverse news stories" instead presented medicines as maligned, warning about hazards and negative consequences. The coverage was judged to be ambiguous, uncertain and contradictory. Prosser (2010)argued the way in which medicines are socially constructed leads to implicit assumptions about modern medicines that could shape opinions. The premise of the current paper is that health professionals' construction of antipsychotics in dementia could have a role in constructing realities about these medicines which if misleading, can contribute to their inappropriate prescribing and use. The aim of this paper is to explore professionals' deliberations about antipsychotic prescribing in dementia using critical discourse analysis (Potter & Wetherell, 1987; Wetherell, Taylor, & Yates, 2001) within a social constructionist approach. Social constructionists view language as constitutive of the truth and therefore give language a key role in negotiating and defining realities (Burr, 2015). The research question is "How do health professionals and care home managers use language to describe and construct antipsychotic medications when discussing their use in dementia?"