Can a chemical cosh ever be compassionate?

According to recent research, one in four patients with dementia are being prescribed antipsychotics in order to sedate them and control difficult behaviour. The Daily Mail has reported this as being due to lazy carers not wanting the inconvenience of actually looking after the elderly. The truth is often different. Last week I was called by a distraught and exhausted wife whose gentle, loving husband has been transformed beyond all recognition by Alzheimer’s.

I didn’t know Bill* before his dementia set in, but by all accounts he was a placid soul. His wife Eileen* described him as a devoted husband and father who wouldn’t hurt a fly. The Bill before me now is very different. Much of the time he sits passively in his chair mumbling incoherently to himself. Other times he gets agitated and angry and he strikes out. He rarely recognises his nearest and dearest and last week in his fear, frustration and confusion he hit his wife Eileen with his walking stick. Eileen was devastated. She keeps telling me that the real Bill would never hurt her and would be mortified if he could comprehend the consequences of his actions. Eileen’s love and commitment towards her husband never ceases to amaze me and it has taken a lot for her to ask me for help. This morning she was in floods of tears as she requested something to sedate him. Her biggest fear is that unless his aggression is controlled she will end up having to put him in a nursing home which in her words “would break both of our hearts.”

Prescribing an antipsychotic for Bill is not something I take lightly and is not my first course of action. We have tried normal antidepressants and also non-pharmacological techniques such as keeping good lighting and getting more help in. Antipsychotics really are a final resort. They are strong drugs with potential side effects and I spend some time talking through the possible pitfalls with Eileen. We decide to start a low dose of Quetiapine. This antipsychotic is not licensed in dementia and may well increase the risk of him having a stroke, but with Bill, I think it is the right decision.

Dignity is a word used a lot with regard to caring for the elderly and some relatives have complained of antipsychotics robbing their elderly relatives of their dignity by over sedating them. It is a delicate balance and each case has to be looked at individually. Antipsychotics are not used for early dementia. They won’t be thrown down the throats of people who have misplaced their door key or forgotten a dental appointment. They are prescribed for agitated disturbed patients during the last stages of this awful disease.

Personally, when I am making these difficult decisions I resort to the simple question of “What would I want if it was me?” If I was suffering with advanced dementia and striking out at my family, would I want to be chemically coshed with an antipsychotic? It might sedate me and I might even die sooner as a result, but wouldn’t that be better than the painful indignity of confused aggression directed towards the people who I love and who love me.

*Real names changed

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