Medications: Guidelines for Treatment

IMPORTANT! This information is meant to be used only for general information, in accordance with current medical information and the practice experience of this geriatrician and should never be used alone, outside of the medical advice of one’s personal physician.

The challenge in formulating guidelines for the treatment of behavioral issues is that dementia patients are highly variable. Two people may look the same, have the same level of dementia, and have similar symptoms. Yet these two patients may respond very differently to the same medication. Thus, treating these symptoms requires trial-and-error medicine. I am upfront about this with the families of my patients. As I always state at the beginning, there is no way to be absolutely sure we can find the right combination of activities, behavioral intervention, pain management and medications that will lead to calm engagement without side effects.

While working several years as a fellow in geriatrics at Mt. Sinai Hospital in Manhattan, as an assistant professor of medicine at University of California-San Francisco, at the Veterans’ Administration Hospital in San Francisco and as a hospice director in the North Bay, I have collaborated for years with geriatric psychiatrists, geriatricians and neurologists.

I have handled a wide variety of cases in which we have enjoyed excellent results treating behavior problems. (There are a handful of patients that medications could not help calm without severe side effects, but they are rare.) It’s a matter of balancing treatment for agitation with loss of abilities like walking.

Treating Behavior is an Art

That said, the Food and Drug Administration has not approved the drugs described below to treat dementia. These medications have serious side effects. Neuroleptics may increase the absolute risk of stroke by approximately 3 percent. They may increase the absolute risk of sudden death by approximately 1 percent. Medical practitioners, families and caregivers should closely monitor patients who are using these medications. even if the patient is calm. It can be very easy to miss further decline or over-sedation.

Remember that geriatric behavioral medicine, is more of an art—and is more about trial and error—than most doctors would like to admit. Physicians often write prescriptions “off-label.” That is, they use a drug to treat symptoms and illnesses not outlined in that drug’s FDA-approved “label”. This happens most often in the treatment of behavioral symptoms of dementia, since the studies do not clearly indicate what to do. That said, it’s important to only use “evidence-based” medicine, proven effective by studies. This area is just incredibly difficult to study. We cannot wait 10 to 20 years for definitive direction when so many of our loved ones need help today.

Hire a Board-Certified Geriatric Specialist

The problems of behavior in dementia have not been emphasized in medical schools until recently. Therefore, if behavioral symptoms become an issue, it’s important to seek out a geriatrician, a geriatric psychiatrist or a neurologist with a focus on dementia.

A geriatrician has had training above the standard internal medicine or family practice residency. Those extra years of training focus on what changes in older individuals lead to specific problems, or “syndromes” such as becoming frail, falling, developing osteoporosis or dementia. Geriatricians use extra caution when prescribing medications. Drugs can often cause symptoms that made the medical appointment necessary in the first place.

First, Do No Harm

My first rule of coping with the behavioral symptoms of dementia is this: Don’t prescribe any medication that will likely make the patient less inhibited.

Many anti-anxiety drugs like Lorazepam/Ativan® or Alprazolam/Xanax®, sleeping pills like Temazepam/Restoril, or Zolpidem/Ambien®—act very much like a couple shots of vodka, or whiskey. They make patients less inhibited, which often worsens the problems of dementia.

Careful with the Tranquilizers

All too often, the disturbing behaviors of dementia patients are treated with tranquilizers of the “benzodiazepine” class. When starting, or if stopped too quickly, these medications have been shown to contribute to delirium, and to decreased brain function. This may lead to agitation and falls. Paradoxically, tranquilizers and anti-anxiety medications may actually make a patient more agitated, or less socially inhibited.

Tranquilizers have their place for emergencies, such as when a patient becomes violent. Short-term use in a hospital may sometimes make sense so that test or procedure may be done to treat a medical issue. However, if used for more than a day or so in patients with dementia, they can lead to oversedation, disinhibition, and paranoia. This increases the danger of falls. If stopped abruptly, the symptoms may become even worse: Insomnia, hypervigilence (an inability to “turn off” mental activity), paranoia, or delirium may result.

Alternatives for Behavioral Problems

Several other classes of drugs and treatment may be used more effectively to treat behavioral symptoms. These include anti-psychotics (“neuroleptics”), antidepressants, and anti-seizure medications. Electro-convulsive therapy, known popularly as “shock treatment,” has evolved considerably since it earned its bad name. It now can be much more humanely administered, and it really can help some patients.

Everyone an Individual

The challenge is this: Everyone’s body chemistry is slightly different. Everyone has a different situation, and a different history. The key is to know where to start and then be available to hear feedback and adjust strategy. Only then can behavioral symptoms be eased, so that life “in the moment” can be pleasant.