What is the recommended treatment for a dementia patient with muscle hypertonicity using antipsychotics (e.g. risperidone) and benzodiazepines (e.g. lorazepam)?

Treatment of Muscle Hypertonicity in Dementia Patients: Avoid Antipsychotics and Benzodiazepines

Neither antipsychotics nor benzodiazepines should be used to treat muscle hypertonicity (paratonia) in dementia patients, as these medications carry significant risks including increased mortality, stroke, falls, and cognitive decline without addressing the underlying muscle tone problem. 1, 2

Critical Safety Warnings

Antipsychotics Are Contraindicated for This Indication

• FDA Black Box Warning: Risperidone and other antipsychotics increase mortality risk in elderly dementia patients (1.6-1.7 times higher than placebo), with deaths primarily from cardiovascular events and infections. 2
• Antipsychotics increase cerebrovascular events including stroke and transient ischemic attacks in elderly dementia patients. 2
• Risperidone is not FDA-approved for any dementia-related symptoms and should only be considered when patients pose imminent danger to themselves or others—not for muscle hypertonicity. 2
• The modest benefits of antipsychotics for behavioral symptoms (effect size SMD -0.21) do not extend to treating muscle tone abnormalities. 3, 4

Benzodiazepines Are High-Risk and Inappropriate

• Benzodiazepines are associated with cognitive impairment, reduced mobility, falls, fractures, and addiction in older adults. 1
• Current consensus guidelines advise benzodiazepines only for short-term use, never for chronic conditions like paratonia. 1
• Lorazepam specifically impairs psychomotor performance and cognitive function in elderly patients, worsening the dementia picture. 5
• Benzodiazepines do not treat muscle hypertonicity and may paradoxically worsen functional status. 1

Evidence-Based Treatment for Paratonia (Muscle Hypertonicity)

First-Line: Non-Pharmacological Interventions

Harmonic techniques and supporting cushions are the only interventions with evidence for treating paratonia in dementia patients. 6

Harmonic Techniques (HT)

• 30-minute sessions of harmonic techniques significantly increase range of motion in both elbow (p<0.001) and knee (p=0.028). 6
• HT reduces pain during morning care (p=0.003) and decreases caregiver-reported discomfort (p=0.001 to p=0.019). 6
• These techniques should be performed before nursing care activities to facilitate easier positioning and reduce distress. 6

Supporting Cushions (SC)

• 30 minutes of positioning with supporting cushions lowers biceps brachii muscle tone (p=0.041) and increases maximal elbow extension (p=0.006). 6
• SC provides sustained benefit for upper limb muscle tone throughout positioning periods. 6

Assessment of Underlying Causes

• Evaluate for pain, which is often undertreated in dementia and can manifest as increased muscle tone and agitation. 3, 4
• Review all current medications for those that may worsen rigidity or muscle tone (anticholinergics, typical antipsychotics if already prescribed). 1
• Assess environmental factors that may be contributing to distress and muscle tension. 3

Deprescribing Strategy If Already on These Medications

Tapering Antipsychotics

• Discontinuation after 3 months can be done successfully without worsening behavioral symptoms in most patients. 1
• Taper gradually rather than abrupt discontinuation, though both methods have been used. 1
• Monitor for symptom relapse, but recognize that continued use carries ongoing mortality and stroke risk. 1, 2

Tapering Benzodiazepines

• Reduce dose by up to 25% every 1-2 weeks as a reasonable starting approach. 1
• Expect variable success rates (27-80% discontinuation rates in studies). 1
• Nursing staff must monitor closely for withdrawal symptoms and provide non-pharmacological support. 1

Common Pitfalls to Avoid

• Do not confuse behavioral agitation with paratonia: Muscle hypertonicity requires physical interventions, not psychotropic medications. 6
• Do not use "as needed" antipsychotics for care resistance: This often represents pain or discomfort from paratonia during movement, not psychiatric symptoms. 3, 4
• Do not continue medications without regular reassessment: If antipsychotics were started for behavioral symptoms, attempt discontinuation after 3 months. 1
• Do not prescribe benzodiazepines for "muscle relaxation": They increase fall risk and cognitive decline without effectively treating paratonia. 1