Medications: Mood-Stabilizers

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.

Sometimes the person just gets very angry, not so much delusional, but with quick change of mood and resistance, or is sexually inappropriate. Using antidepressants is often the best way to address these symptoms. Dr. Volicer, who had done research in this area also suggests to use the neuroleptics, if the antidepressants are not effective. However, if the person has just anger, then an alternative to using the Neuroleptics, that have the increased stroke risk would be the mood stabilizers. This class were originally used for seizure control, then for use in manic depressive disease. There is controversy in the use of these medications. However, this would be an option, especially if the option was to use a benzodiazepine, which will lead to more disinhibition or agitation when used regularly.

  • Valproic Acid/Depakote® may be helpful for decreasing severe anger and mood lability, that does not respond to antidepressants. Also not FDA approved for use in dementia. A study several years ago did not show this medication to be helpful, but it allowed the use, but did not identify which patients were on Aricept or Lorazepam, which also effect behavior. Side effects include liver inflammation or decreased blood cell counts, and too high a dose can lead to sedation and aspiration.Valproic Acid/Depakote® can be very tricky to use with elders who are frail. However, for a patient who is climbing walls, trying to escape, physically lashing out at family and staff, this drug can ratchet back the aggression more quickly than other drugs.
    The major complication for use in the elderly is the adverse effect on walking and from sedation. Depakote® often irritates the stomach and the pill cannot be crushed into food to ease this. Work-arounds include Depakote® sprinkles, which are expensive, and Depakene® liquid, which is less expensive but may be more irritating to the digestive system.
  • Neurontin/Gabapentin®, another anti-seizure drug, is also approved for use in treating shingles. It has been used “off-label” for peripheral neuropathy, a problem with the nerves that carry messages to and from the brain and spinal cord, resulting in various symptoms such as burning pain, numbness.

While I was UCSF working in long-term care, I treated many patients who had abused the medications commonly used to calm people, such as opiates. I found that Gabapentin® avoided addiction issues and helped calm a wide variety of these patients: a man with post-traumatic stress disorder who had to stay in the hospital for antibiotics, another who terrible sciata, another with spinal pain.

Likewise, I have found that Gabapentin® can effectively calm some dementia patients. It may decrease anger and anxiety for some, but for others it may do little but make them sleepy. Again, the starting dose should be very small, say 50 milligrams administered by a reliable caregiver.