Medicines for behavioral problems

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When Alzheimer's disrupts memory, language, thinking and reasoning, these effects are referred to as "cognitive symptoms" of the disease. The term "behavioral and psychiatric symptoms" describes a large group of additional symptoms that occur to at least some degree in many, but by no means all, individuals with Alzheimer's.

In early stages of the disease, people may experience personality changes such as irritability, anxiety or depression. In later stages, other symptoms may occur, including sleep disturbances; agitation (physical or verbal outbursts, general emotional distress, restlessness, pacing, shredding paper or tissues, yelling); delusions (firmly held belief in things that are not real); or hallucinations (seeing, hearing or feeling things that are not there).

Many individuals with Alzheimer's and their families find behavioral and psychiatric symptoms to be the most challenging and distressing effects of the disease. These symptoms are often a determining factor in a family's decision to place a loved one in residential care. They also often have an enormous impact on care and quality of life for individuals living in long-term care facilities.


Medical evaluation

A person exhibiting behavioral and psychiatric symptoms should receive a thorough medical evaluation, especially when symptoms come on suddenly. Treatment depends on a careful diagnosis, determination of the possible causes, and the types of behavior the person is experiencing. With proper treatment and intervention, significant reduction or stabilization of the symptoms can often be achieved.

Symptoms often reflect an underlying infection or medical illness. For example, the pain or discomfort caused by pneumonia or a urinary tract infection can result in agitation. An untreated ear or sinus infection can cause dizziness and pain that affect behaviors. Uncorrected problems with hearing or vision may also have an impact.

Side effects of prescription medication are another common contributing factor to behavioral symptoms. Side effects are especially likely to occur when individuals are taking multiple medications for several health conditions, creating a potential for drug interactions.

Non-drug treatment strategies

There are two distinct types of treatments for behaviors: non-drug strategies and prescription medications. Non-drug interventions should be tried first. In general, steps to managing behaviors include (1) identifying the behavior, (2) understanding its cause, and (3) adapting the caregiving environment to remedy the situation.

Correctly identifying what has triggered symptoms can often help in selecting the best approach. Often the trigger is some sort of change in the person's environment:
- change in caregiver
- change in living arrangements
- travel
- hospitalization
- presence of houseguests
- bathing
- being asked to change clothing

A key principle of intervention is redirecting the person's attention, rather than arguing, disagreeing, or being confrontational. Additional strategies include the following:
- simplify the environment
- simplify tasks and routines
- allow adequate rest between stimulating events
- use labels to cue or remind the person
- equip doors and gates with safety locks
- remove guns
- reduce risk of fires with extra smoke alarms and control access to the stove
- use lighting to reduce confusion and restlessness at night


Medications to treat behavioral symptoms

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 effect 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. Thoughtful choice of a drug may also maximize its benefit. For example, some antidepressants may also help people sleep better.

People with dementia are susceptible to serious side effects, including a slightly increased risk of death from antipsychotic medications. Risk and potential benefits of a drug should be carefully analyzed for any individual.

Some examples of medications commonly used to treat behavioral and psychiatric dementia symptoms are listed below. These lists do not include every drug used for these purposes. Doctors base their choice of medication on many factors, including the underlying cause of dementia and an individual's symptoms, living situation, caregiving arrangement, and coexisting health conditions.

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 (Geodon)
- Older first-generation drugs such as haloperidol (Haldol)

The decision to use an antipsychotic drug needs to be considered with special care. Recent studies have shown that these drugs are associated with a slightly increased risk of death in older adults with dementia. The FDA has labeled the drugs with a warning about this risk and a reminder that they are not approved to treat dementia symptoms.

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.

Although antipsychotics are among the most frequently used medications for treating agitation, some physicians may prescribe an anticonvulsant/mood stabilizer, such as divalproex (Depakote), for hostility or aggression.

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.

Medications for sleep problems

Some medications are approved specifically by the U.S. Food and Drug Administration (FDA) as "sleeping pills." Most physicians tend to avoid prescribing "sleeping pills" for older adults with dementia, since in this group these drugs may have serious side effects, including incontinence, problems with balance, falls or increased agitation.

One widely used alternative is the antidepressant trazodone (Desyrel), which tends to make people sleepy.

Anti-anxiety medications are also sometimes used.

Physicians also recommend that individuals with dementia avoid over-the-counter sleep remedies. The active ingredient in many of these preparations is diphenhydramine (Benadryl), an antihistamine that tends to make people feel drowsy. Diphenhydramine further suppresses the activity of one of the main brain cell messenger chemicals whose activity is reduced by Alzheimer's disease.

Examples of over-the-counter sleep aids containing diphenhydramine that should be avoided include:
- Compoz
- Nytol
- Sominex
- Unisom

Diphenhydramine is also an ingredient in many "nighttime" or "PM" versions of popular pain relievers and cold and sinus remedies.