A recent analysis in JAMA Psychiatry revealed a major shift in global prescribing patterns: antipsychotic use in older adults (65+) has increased sharply over the past decade, and many individuals remain on these medications for long periods. Although this data is from the US, the pattern closely mirrors what we see in India—in clinics, hospitals, long-term care homes and home-based elder care.

As India’s ageing population grows, more families are facing difficult behavioural symptoms in dementia: agitation, restlessness, sleeplessness, hallucinations, aggression, and wandering. Antipsychotics often become the default solution.

But these medicines carry risks—especially in older adults.

This article explains the medications in simple terms, includes Indian brand names, and offers guidance for families navigating these decisions.

What Exactly Are Antipsychotics?

Antipsychotics are medicines that help control severe behavioural symptoms, psychosis and agitation. They are traditionally meant for schizophrenia and bipolar disorder, but are also used—often off-label—for behavioural problems in dementia.

Commonly Used Antipsychotics in India (With Brand Names)

Second-generation (newer) antipsychotics

• Risperidone – Risperdal, Risnia, Sizodon

• Olanzapine – Olanex, Oleanz, Zyprexa

• Quetiapine – Quepin, Qutan, Seroquel

• Aripiprazole – Arpizol, Abilify, Arip MT

• Paliperidone – Invega, Palido OD, Paliap

• Ziprasidone – Zipsydon

• Clozapine – Clozaril, Sizopin, Clozine

• Lurasidone – Latuda, Lurace

• Cariprazine – Caripill, Cariprazine Sun

• Brexpiprazole – Rexulti (used for agitation in Alzheimer’s, limited Indian availability)

First-generation (older) antipsychotics

• Haloperidol – Haloperidol, Serenace, Haldol

• Chlorpromazine – Chlorproma, CPZ

• Trifluoperazine – Stelazine, Trinicalm

• Fluphenazine (Depot) – Flupaday, Moditen Depot

• Thioridazine – rarely used now due to cardiac risks

• Perphenazine – limited availability in India

Even the “newer” medicines carry serious risks in older adults—especially those with dementia.

Why Antipsychotic Use in Elders Is Increasing

1. Rising dementia cases

India is moving toward 20+ million people with dementia by 2050. Behavioural symptoms are common and distressing.

2. Caregiver burnout

Families struggle with:

• Sleepless nights

• Aggressive outbursts

• Wandering

• Repeated shouting or restlessness

Doctors may prescribe antipsychotics quickly to provide relief.

3. Shortage of geriatric psychiatrists

India has far fewer specialists than needed, so many prescriptions come from:

• General physicians

• Neurologists

• Emergency doctors

• Non-specialist psychiatrists

• Nursing homes and elder-care homes

4. Limited staff in care homes

Behavioural symptoms are often managed through medication instead of structured routines or behavioural approaches.

5. Misbeliefs about “quick calming”

Many believe antipsychotics make dementia easier to manage. They may, temporarily—but at a cost.

The Real Risks: What Every Family Must Know

Antipsychotics in older adults—especially those with Alzheimer’s, Lewy body dementia or vascular dementia—can lead to:

• Excessive sleepiness and increased falls

• Worsening confusion and memory decline

• Stroke

• Heart rhythm problems

• Sudden cardiac death

• Pneumonia

• Severe rigidity or Parkinsonian symptoms

• Metabolic issues: weight gain, diabetes, cholesterol

The FDA and European agencies have clear warnings:
Antipsychotics increase mortality in dementia.

India has no mandatory warning labels for caregivers—so awareness becomes even more important.

Are Some Antipsychotics Safer Than Others?

Here is a practical, India-specific summary:

• Risperidone – Effective for aggression; higher risk of stroke

• Olanzapine – Sedating; major weight and sugar effects

• Quetiapine – Often used for sleep; causes falls and confusion

• Aripiprazole – Lower metabolic effects; still risky in dementia

• Haloperidol – Useful in emergencies only; highest mortality and side-effect burden

• Clozapine – Never first-line in elders; requires blood monitoring

No antipsychotic is truly safe in dementia.
They may have a role—but as a last resort, not a first step.

When Antipsychotics Are Appropriate

They may be justified when:

• The older adult is hallucinating and terrified

• There is violent behaviour risking injury

• The person is extremely restless and cannot be redirected

• Behaviour poses danger (pulling out tubes, hitting caregivers)

• Psychosis from schizophrenia or bipolar disorder continues into old age

Even then, lowest dose, short duration, and regular monitoring are essential.

Better Alternatives: What Actually Helps Without Medication

Families often find great relief from simple, non-drug approaches:

• Correcting sleep cycles and reducing daytime naps

• Managing constipation, infections, dehydration and pain

• Reducing noise, clutter and overstimulation

• Creating predictable daily routines

• Playing old songs the person recognises

• Gentle massage, warm lighting, familiar objects

• Engaging the person in light chores or meaningful activities

• Behavioural strategies taught by a clinician

These methods often reduce agitation better than medicines—and with no side effects.

Five Questions Every Family Should Ask the Doctor

1. Why is this medicine needed?

2. Can the behaviour be managed without medication?

3. Is this the lowest possible dose?

4. How long will we use it before reviewing or tapering?

5. What signs of side effects should we watch for?

Good care starts with good questions.

The Big Picture: India Needs a Compassion-Centered Approach to Elder Care

As antipsychotic use rises, we risk treating behaviours rather than treating people.

Older adults deserve:

• more trained caregivers,

• dementia-friendly clinics,

• community support,

• non-drug interventions,

• early specialist involvement, and

• respectful, person-centred care.

Medicines can help—but they must not replace compassion, patience, and understanding.

About the Author

Dr. Srinivas Rajkumar T, MD (AIIMS), DNB, MBA (BITS Pilani)
Consultant Psychiatrist & Neurofeedback Specialist
Mind & Memory Clinic, Apollo Clinic Velachery (Opp. Phoenix Mall)
✉ srinivasaiims@gmail.com 📞 +91-8595155808