Text adapted from "The patient with dementia" in Psychiatry in primary care by Kenneth Le Clair, Dallas Seitz and Julia Kirkham. (CAMH, 2019).
Several medications have demonstrated efficacy in treating certain BPSD behaviours (see Table 3). Behaviours that may respond to pharmacotherapy include:
- verbal aggression
- sleep disturbances
- persistent delusions or hallucinations
- sexually inappropriate behaviour accompanied by agitation.
Behaviours that generally do not respond to pharmacotherapy include wandering, repetitive questioning or vocalizing, abnormal eating, inappropriate dressing or undressing, and inappropriate defecation or urination
Atypical antipsychotics are the best supported treatment for severe agitation and psychosis in dementia that is unresponsive to non-pharmacological interventions. The potential benefits of these medications must be balanced with their potential serious adverse effects. Atypical antipsychotics have been associated with an increased risk of death and stroke when used to treat BPSD. Patients need to be warned of the potential risks and monitored carefully for adverse events.
Other medications with some evidence for use in BPSD include selective serotonin reuptake inhibitors (SSRIs) (e.g., citalopram) and the antidepressant trazodone. There is little or no evidence to support the use of benzodiazepines or other hypnotics. Moreover, there are significant safety concerns associated with their use, so they are not recommended.
General Principles of Pharmacotherapy
When treating a patient with pharmacotherapy, keep these principles in mind:
- Start low and go slow.
- Use one medication at a time.
- Use medications at optimal dose and duration prior to switching or discontinuing.
- Use medications that will not worsen cognition.
- Be aware of drug–drug interactions.
As dementia progresses, certain behaviours may no longer be problematic and you may be able to gradually discontinue medications after several consecutive months of behavioural stability.