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Pharmacological treatment of the behavioral and psychological symptoms of dementia should only be undertaken when one of the following situations is present:
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The symptoms are causing distress to the patient or caregiver
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The symptoms are dangerous to the patient or others
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There is a specific condition for which there is a known treatment that is both efficacious and safe.
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Non-pharmacological approaches have been tried ( Chapter 23 ).
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Medications to treat cognition, cholinesterase inhibitors and memantine, are helpful in treating the behavioral and psychological symptoms of dementia, and in general should be used first.
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Medical illnesses should always be looked for and treated.
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General principles of pharmacotherapy for behavioral and psychological symptoms of dementia:
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Accurately diagnose the underlying dementia
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Identify and measure specific target symptoms
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Start low, go slow—but go
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Instruct the caregiver and patient both verbally and in writing
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Remove unneeded medications
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Change only one medication at a time.
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Pharmacotherapy for depression
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SSRIs are first-line therapy
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Bupropion (Wellbutrin) and venlafaxine (Effexor) can also be used.
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Pharmacotherapy for anxiety
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SSRIs are first-line therapy
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Atypical antipsychotics can be used with caution.
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Pharmacotherapy for pseudobulbar affect
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Dextromethorphan/quinidine (Nuedexta) may be used (see text for details).
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Pharmacotherapy for insomnia
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Address sleep hygiene issues
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Try non-pharmacological treatment
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Treat any underlying sleep disorder
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Treat any underlying depression or anxiety
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Can try a small dose of a long-acting stimulant medication to keep patient awake and alert during the day (see text)
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Can try a small dose of a sedative if necessary (see text).
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Pharmacotherapy for psychosis
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Accurately diagnose the cause of the dementia.
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Atypical antipsychotics are the preferred treatment.
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Pharmacotherapy for agitation
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Characterize and diagnose the nature of the agitation and any underlying or comorbid condition(s) present.
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If depression or anxiety is present, start with an SSRI.
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If psychosis (hallucinations or delusions) is present, start with an atypical antipsychotic.
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If no specific cause for the agitation can be determined, start with an atypical antipsychotic if rapid treatment is necessary; start with an SSRI if treatment may be initiated more slowly.
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Behavioral and psychiatric crises
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Psychiatric hospitalizations allow medications to quickly be withdrawn and added in a safe setting.
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Use of SSRIs in dementia
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SSRIs are generally well tolerated.
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SSRIs can help with depression, anxiety, and agitation
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We generally use a low dose of:
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Sertraline (Zoloft) target 75–150 mg QD; general range for dementia 50–200 mg
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Citalopram (Celexa) target 20 mg QD; general range for dementia 10–40 mg
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Escitalopram (Lexapro) target 10 mg QD; general range for dementia 5–20 mg.
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Main side effects: gastrointestinal upset and sexual dysfunction.
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Use of atypical antipsychotics in dementia
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Atypical antipsychotics may impair cognition, be sedating, cause parkinsonism, lead to falls, cause hyperglycemia, increase the risk of heart disease and strokes, lower the seizure threshold, and cause dystonias and tardive dyskinesia
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After informed consent, atypical antipsychotics should be used for as brief a period as possible, when the patient is in a situation in which he or she can be regularly observed
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We generally use:
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Risperidone (Risperdal); range for dementia 0.25–1 mg QD-BID
Little sedation, recommended for daytime use
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Quetiapine (Seroquel); range for dementia 12.5–200 mg QD-BID
Sedating, recommended for use at bedtime
Less likely than others to cause or worsen parkinsonism; recommended for patients with dementia with Lewy bodies
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Aripiprazole (Abilify); range for dementia 2.5–5 mg QD-BID
Very little sedation, recommended for daytime use
Least effect on carbohydrate metabolism.
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Please see text for additional discussion of atypical antipsychotics prior to use.
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Note that the medications discussed in this chapter are powerful drugs with dangerous side effects and adverse reactions and are not approved by the US Food and Drug Administration for use in patients with dementia. See CAUTION in text.
In some cases non-pharmacological treatment of the behavioral and psychological symptoms of dementia is not sufficient. In these instances the judicious use of appropriate medications can be beneficial. Our rule of thumb in introducing pharmacological treatment for the behavioral and psychological symptoms of dementia is that we only do so when one of the following situations is present:
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The symptoms are causing distress to the patient or caregiver
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The symptoms are dangerous to the patient or others
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There is a specific condition for which there is a known treatment that is both efficacious and safe.
CAUTION: Note that the medications discussed in this chapter are powerful drugs with dangerous side effects and adverse reactions and are not approved by the US Food and Drug Administration (FDA) for use in patients with dementia. All recommendations in this chapter are based upon the combination of published research studies, clinical experience, and use in non-demented patients. The physician (or other provider) must use appropriate clinical judgment as to whether the potential benefit of prescribing one of these medications “off-label” outweighs the risks to the patient. In addition to reviewing side effects and adverse reactions, the physician (or other provider) must review the FDA-approved package insert, including black box warnings, contraindications and cautions, drug interactions, and safety and monitoring, before prescribing. The authors take no responsibility in the prescribing of one or more of these medications by the physician (or other provider) to his or her patients.
In general, pharmacotherapy for patients with behavioral and psychological symptoms of dementia falls into three general categories.
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Drugs to treat cognition . Treating the underlying dementing disorder may also treat behavioral and psychological symptoms of dementia. Treatment with cholinesterase inhibitors and memantine has been shown to decrease the symptoms in patients with Alzheimer’s disease, dementia with Lewy bodies, and vascular dementia (for review, see ). Note, however, that in some patients with frontotemporal dementia cholinesterase inhibitors will sometimes worsen the behavioral and psychological symptoms of dementia.
Consider three of the most common delusions in dementia:
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Possessions are being stolen
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House is not their home
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Spouse is not their spouse.
These delusions are all caused in part by impaired memory. The patient who thinks people are stealing her jewelry typically put it away for safekeeping, then forgot that she moved it (and where she put it). The patient who does not believe that his house is his home is usually remembering an earlier home—most often the home of his childhood—and thinks that is where he still lives, and perhaps that his mother is waiting for him! The patient who does not believe that her husband is her spouse is likely remembering when the husband looked younger (or perhaps is remembering a previous husband). Because memory dysfunction contributes to these delusions, it should not be surprising that improving patients’ memories can reduce or eliminate these types of delusions. For this reason, when we believe that the patient’s delusions are caused by memory problems, we always start by making sure that the memory medication—that is, the cholinesterase inhibitor—is maximized.
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Drugs to treat comorbid illnesses . Although it may seem obvious, it is well worth reiterating that patients with dementing disorders often have comorbid illnesses that, although not the cause of their dementia, may be contributing to their poor cognition and their behavioral and psychological symptoms. For example, whenever we detect a change in cognition over a matter of days in one of our patients we always suspect an infection (such as a urinary tract infection or pneumonia) or another medical cause. Treating the medical illness should correct the sudden deterioration in behavior and cognition.
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Drugs to treat specific symptoms of behavioral and psychological symptoms of dementia . Depression, anxiety, insomnia, hallucinations, delusions, and agitation are all common in dementing illnesses. These conditions also all have specific pharmacological treatment that can be helpful when implemented skillfully and judiciously.
General Principles of Pharmacotherapy for the Behavioral and Psychological Symptoms of Dementia
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Accurately diagnose the underlying dementia . Treatment of behavioral and psychological symptoms of dementia will vary depending upon the underlying dementing disorder. For example, as we saw in Chapter 5 , although patients with dementia with Lewy bodies experience visual hallucinations, one must be very cautious in treating them because many antipsychotic drugs exacerbate their parkinsonian symptoms. Knowing that the patient has dementia with Lewy bodies will lead to the use of quetiapine (Seroquel) as first-line therapy, rather than risperidone (Risperdal), since the former is less likely to exacerbate their parkinsonism ( Box 24-1 ).
Box 24-1
Use of Atypical Antipsychotics in Dementia
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Non-pharmacological therapies should be used first to reduce the use and/or dose of atypical antipsychotics in dementia (see Chapter 23 and for review, ).
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Atypical antipsychotics may impair cognition, be sedating, cause parkinsonism, lead to falls, cause hyperglycemia, increase the risk of heart disease and strokes, lower the seizure threshold, and cause dystonias and tardive dyskinesia. Some studies suggest that these risks of adverse events offset the efficacy of atypical antipsychotics for the treatment of dementia ( ).
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Atypical antipsychotics should be used for as brief a period as possible, and only when the patient is in a situation in which he or she can be regularly observed.
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Complications often occur with the use of atypical antipsychotics in patients with dementia; this possibility of complications should be discussed with the patient and caregiver, and consent for the use of these medications should be obtained and documented in the medical record.
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There are a number of atypical antipsychotics to choose from. The ones typically used in dementia are (target dose is always the lowest effective dose):
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Risperidone (Risperdal); range for dementia 0.25–1 mg QD-BID. Available in tablets and also 1 mg/mL solution. One of the less sedating atypical antipsychotics, ideal for use during the day when a daytime medication is needed ( ). Also useful in liquid form when pills cannot be swallowed. Can cause prolactinemia and exacerbate osteoporosis.
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Quetiapine (Seroquel); range for dementia 12.5–200 mg QD-BID. Somewhat sedating, recommended for use at bedtime although can be used during the day in small doses. Less likely than others to cause or worsen parkinsonism; ideal for patients with dementia with Lewy bodies.
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Aripiprazole (Abilify); range for dementia 2.5–5 mg QD-BID. One of the least sedating atypical antipsychotics. Least effect on carbohydrate metabolism.
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Ziprasidone (Geodon); intramuscular (IM) range for dementia: 20 mg IM QD-TID. Particularly useful when an intramuscular medication is needed. Switch to PO as soon as possible.
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Olanzapine (Zyprexa); range for dementia 1.25–10 mg QD.
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If one atypical antipsychotic is not effective, others may be.
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Atypical antipsychotics should be used with caution in patients with dementia.
Related posts:
Approach to the Patient with Memory Loss, Mild Cognitive Impairment, or Dementia
Jakob-Creutzfeldt Disease
Progressive Supranuclear Palsy
Legal and Financial Issues in Memory Loss, Alzheimer’s Disease, and Dementia
Evaluating the Behavioral and Psychological Symptoms of Dementia
Other Disorders That Cause Memory Loss or Dementia
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