Antipsychotic Review in BPSD — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryAntipsychotic Review in BPSDMRCPsych Paper B

A 78-year-old woman with moderate Alzheimer's disease develops persistent aggression that places others at risk of harm. Potential clinical and environmental causes have been addressed, but psychosocial and environmental interventions over 4 weeks have been ineffective. Risperidone is prescribed and titrated to 0.5 mg twice daily. At the planned 6-week review, the aggression has resolved and there is no longer a risk of harm. What is the most appropriate next step?

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Correct answer: D — Review and discontinue risperidone

Explanation lettering: C = shown as A · A = shown as B · D = shown as C · B = shown as D

The correct answer is B. NICE NG97 (recommendations 1.7.6–1.7.7) requires antipsychotics in dementia to be used at the lowest effective dose for the shortest possible time, reassessed at least every 6 weeks, and stopped when there is no clear ongoing need. In addition, the UK risperidone SmPC licenses it only for short-term treatment (up to 6 weeks) of persistent aggression in moderate to severe Alzheimer's dementia with risk of harm. As the aggression and associated risk have resolved at 6 weeks, risperidone should be discontinued after review and discussion with the patient and her family or carers, with psychosocial measures continued. Indefinite continuation (A) needlessly prolongs cerebrovascular and mortality risks. Dose escalation (C) is illogical when symptoms have settled. Switching to olanzapine (D) offers no benefit and is off-label for this indication. Regular lorazepam (E) increases sedation, falls and cognitive worsening and is not indicated.

Reference: NICE NG97 Dementia: assessment, management and support for people living with dementia and their carers, recommendations 1.7.6–1.7.7 (2018): https://www.rightdecisions.scot.nhs.uk/m/1842/nice-guidance-dementia-assessment-management-and-support-for-people-living-with-dementia-and-their-carers.pdf ; Risperidone 0.5mg SmPC (emc): https://www.medicines.org.uk/emc/product/8208/smpc