My Demented Mom blog posts about psychiatric medication:

• Good News, US Senators Seek to Cut Misuse of Antipsychotics 
• When There’s Nothing You Can Do You Let Go
• You Can Never Undo the Past
• Stop
• Information sourced from the Alzheimer’s Association

Medications to treat behavioral symptoms

If non-drug approaches fail after they have been applied consistently, introducing medications may be appropriate when individuals have severe symptoms or have the potential to harm themselves or others. Medications can be effective in some situations, but they must be used carefully and are most effective when combined with non-drug approaches.

Medications should target specific symptoms so their effects can be monitored. In general, it is best to start with a low dose of a single drug. Effective treatment of one core symptom may sometimes help relieve other symptoms. For example, some antidepressants may also help people sleep better. Individuals taking medications for behavioral symptoms must be closely monitored. People with dementia are susceptible to serious side effects, including stroke and an increased risk of death from antipsychotic medications.

Sometimes medications can cause an increase in the symptom being treated. Without careful evaluation, some medical providers will increase rather than decrease the dose, putting the person at greater risk. Risk and potential benefits of a drug should be carefully analyzed for any individual.

When considering use of medications, it is important to understand that no drugs are specifically approved by the U.S. Food and Drug Administration (FDA) to treat behavioral and psychiatric dementia symptoms. Some of the examples discussed here represent “off label” use, a medical practice in which a physician may prescribe a drug for a different purpose than the ones for which it is approved.

Antidepressant medications for low mood and irritability

• citalopram (Celexa®)
• fluoxetine (Prozac®)
• paroxetine (Paxil®)
• sertraline (Zoloft®)
• trazodone (Desyrel®)

Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance

• lorazepam (Ativan®)
• oxazepam (Serax®)

Antipsychotic medications for hallucinations, delusions, aggression, hostility and uncooperativeness

• newer “atypical” agents such as aripiprazole (Abilify®); olanzapine (Zyprexa®); quetiapine (Seroquel®); risperidone (Risperdal®); and ziprasidone (Geoden®)
• older first-generation drugs such as haloperidol (Haldol®)

The decision to use an antipsychotic drug needs to be considered with extreme caution. A recent analysis shows that atypical antipsychotics are associated with an increased risk of stroke and death in older adults with dementia. The FDA has asked manufacturers to include a “black box” warning about the risks and a reminder that they are not approved to treat dementia symptoms. The warning states: “Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo.”

The analysis states that while risperidone and olanzapine are useful in reducing aggression and risperidone reduces psychosis, both drugs are associated with severe side effects. Despite some efficacy, these drugs should not be used routinely with dementia patients, unless the person is in severe distress or there is a marked risk of harm.

To maximize the chances of effectiveness, the choice of a particular drug, how long it should be used and when it should be discontinued all need to be carefully tailored to an individual’s symptoms and circumstances. The underlying cause of a person’s dementia may also influence the selection of a drug. For example, it is generally considered inadvisable for individuals with dementia with Lewy bodies (DLB) to take antipsychotic drugs.

Many experts recommend that use of drugs to treat agitation, aggression, hallucinations and delusions in persons with dementia be managed by a physician with experience and interest in this area.