Medications: Treating Dementia’s Behavioral Symptoms

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.

Dementia commonly makes people anxious, paranoid, angry, depressed, even delusional. They may become compulsive, or obsessed with repeating some task. They may ask the same question over and over. A person may become convinced that people are stealing from them. They may come to believe that their spouse is an imposter or cheating on them (often a difficult delusion to treat). They become angry and paranoid with visitors and doctors. They may misinterpret social cues and become convinced that caregivers and staff want to become romantic with them.

It’s key to investigate whether behavioral problems stem from practicalities. Anger, paranoia, inappropriate action can grow from a wet Depends™, from hunger or from fatigue. The patient may be developing a bedsore from sitting or lying in the same position for more than two hours. They may have suddenly acute arthritis pain. They may be annoyed about a neighbor’s yelling, or a bladder that will not empty, or serious constipation that hurts. All these issues should be considered and addressed before proceeding with more involved intervention.

Activity is Crucial

It’s crucial for both families and caregivers to understand that the lack of something to do can actually make behavioral problems worse. All dementia patients need meaningful activities to fill their days. What this means is different for everyone. One may like gardening, while another may spend hours on puzzles or manipulating simple gears. The trick is to find the right balance for each person, to allow them to enjoy what capacities they still retain.

The key point is that it’s not enough to park someone in front of a TV. If someone sits at home all day with a caregiver who just looks at them, she may get into trouble, acting out from frustration or boredom. Meaningful activity becomes even more important as the condition progresses, and the patient’s connection to reality becomes ever more tenuous. For instance, if an elder with advanced dementia watches a news report about flooding, he may become convinced that he is in danger but unable to communicate this. The resulting anxiety may lead to distressing behavior.

When Medication for Behavior Makes Sense

If the behavioral problems do not interfere with medical and personal care, then it may be best to ignore them as much as possible. But often, behavioral issues make caring for patients difficult or impossible. In these cases, it makes sense to discuss the risks and benefits of treating behavioral/psychological issues with medication.

Controversy over Medication

Treating the behavioral symptoms of dementia remains controversial, largely because there’s a sense that it’s an insoluble problem with little evidence for effective treatment. For instance, a recent review of many studies of medications for behavioral symptoms concluded that nothing works. Paradoxically, this has resulted in the common prescription of drugs like Lorazepam/Ativan®, a common anti-anxiety medicine. While drugs like these may yield short-term results, they are highly addictive. And, if used for more than a couple days, they may actually increase behavioral problems, rather than decreasing them.

Some studies have concluded that Citalopram/Celexa® decreases agitation, but it doesn’t work for all patients. Still, it’s a better choice than Lorazepam, unless a patient really needs to be sedated or restrained. Just as most drugs are not tested in children under six, fewer drug studies focus on complicated medical patients over 65, or patients with dementia.

Behavioral Symptoms CAN Be Treated

Nevertheless, geriatricians, geriatric-psychiatrists and I have found empirically that the behavioral symptoms of dementia can be treated. It’s important to focus on the goals of care for dementia patients. Are we trying to treat every disease, prevent every side effect and prolong life despite the patient’s possible suffering? Or, are we trying make the patient as functional as possible with a minimum of distress?

Treating behavioral symptoms can improve patients’ lives. (Done incorrectly, it can also make things worse.) But, when relieved of anxiety, delusion, compulsion, paranoia and anger, dementia patients can live more fully in the moment. When behavior symptoms are treated, loved ones and caregivers do not need to be on edge, accused of being jailers, wondering when the next outburst or crisis will come. Patients can enjoy their friends and family. They can make the most of the time left to them.

I have seen these medicines for behavioral problems make a huge difference in the lives of my patients. They have brought comfort to families. Still, these drugs cannot be interchanged like various tranquilizers, or like the statins used to lower cholesterol. All drugs have pluses, and minuses. While it’s important for patients, or their families, to know medication basics, be sure to discuss these options in detail with your doctor.