Medicines to treat behavior problems in Alzheimer's disease and other dementias

Medicines can be used to treat behavior problems caused by Alzheimer's disease and other diseases that cause dementia. They should be used only after other nondrug approaches have failed to improve a person's symptoms. Medicine may be needed when the person is in danger of harming himself or herself or others or when the caregiver is unable to deal with the situation using other means.

Antipsychotic medicines may help relieve more severe agitation or psychosis (disordered thought processes).

• Low doses may make the person more comfortable by reducing certain symptoms, such as delusions, suspicion of others (paranoia), hallucinations, hostility, or agitation.
• These medicines also may improve sleep.
• The side effects may make some symptoms of Alzheimer's disease worse, such as apathy, withdrawal from family and friends, and inability to think clearly.
• These are powerful medicines. They commonly cause dizziness, drowsiness, movement disorders that resemble Parkinson's disease, low blood pressure upon standing (orthostatic hypotension), and other side effects.

Examples of medicines sometimes used to treat hallucinations, paranoia, and severe agitation in people with dementia include haloperidol (Haldol), risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa).

Some of these medicines have some known risks:

• In April 2005, the U.S. Food and Drug Administration (FDA) issued a public health advisory to alert people about the higher risk of death in people with dementia who used atypical antipsychotics. Atypical antipsychotics include Zyprexa, Risperdal, Seroquel, Clozaril (clozapine), Geodon (ziprasidone), and Abilify (aripiprazole). These drugs are not approved to treat dementia.¹ The FDA asked the makers of these drugs to include a boxed warning on their labels that describes the increased death risk and notes that these drugs are not approved to treat dementia.¹
• The makers of Risperdal have issued a warning that older adults taking this medicine may have a slightly higher risk of stroke.

The FDA warning about an increased risk of death has only been issued for atypical (or newer) antipsychotics. But there is evidence that the older, conventional antipsychotics may not be any safer.^{2, 3} Discuss these risks with the person's doctor before deciding to try these medicines.

Antianxiety medicines, including minor tranquilizers, relieve anxiety and mild agitation and may help calm the person. However, they can cause drowsiness if the dose is too high. When minor tranquilizers are needed, short-term or occasional use often is better than continuous use.

Oxazepam (Serax) and lorazepam (Ativan) are minor tranquilizers sometimes used in treating dementia. Another antianxiety medicine called buspirone (BuSpar) also can be tried.

• These medicines may increase confusion and upset the person's balance, raising the risk of falls.
• A person may become dependent on these medicines over time, causing even worse symptoms when he or she suddenly stops taking them. To avoid this problem, these drugs usually are stopped gradually after a few weeks of use.

Anticonvulsant medicines, such as carbamazepine (Tegretol) or valproic acid (Depakene), may be used to control agitation, violent behavior, and mood swings caused by dementia. However, the U.S. Food and Drug Administration (FDA) has not approved their use for this specific problem.

Other medicines that may be used to treat agitation include trazodone (Desyrel) or a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), or escitalopram (Lexapro). However, research on the effectiveness of these medicines in Alzheimer's disease and other dementias is limited.

FDA Advisories. The U.S. Food and Drug Administration (FDA) has issued:

• An advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. This is especially important at the beginning of treatment or when the doses are changed.
• A warning on anticonvulsants and the risk of suicide and suicidal thoughts. The FDA does not recommend that people stop using these medicines. Instead, people who take anticonvulsant medicine should be watched closely for warning signs of suicide. People who take anticonvulsant medicine and who are worried about this side effect should talk to a doctor.

See Drug Reference for more information about all of these medicines. (Drug Reference is not available in all systems.)

Citations

1. U.S. Food and Drug Administration (2005). FDA issues public health advisory for antipsychotic drugs used for treatment of behavioral disorders in elderly patients. FDA Talk Paper T05-13. Available online: http://www.fda.gov/bbs/topics/ANSWERS/2005/ANS01350.html.

2. Wang PS, et al. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. NEJM, 353(22): 2335–2341.

3. Kales HC, et al. (2007). Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric medications. American Journal of Psychiatry, 164(10): 1568–1576.