Dementia: Medications for Treating Behavioural and Psychological Symptoms

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
anxiety
agitation
sadness
insomnia
sleep disturbances
hyperactivity
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

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

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.

Table 3 Medications for behavioural and psychological symptoms of dementia

Medication	Respiridone	Olanzapine	Quetiapine	Aripiprazole	Citalopram	Trazodone
Indications	Atypical antipsychotics are best supported treatments for BPSD				Similar to antipsychotics Second-line treatment for severe aggression or agitation (start with atypical)	Sleep disturbance associated with dementia Treatment of behaviours in frontotemporal dementia
Initial dose	.25 od or bid	2.5 mg po qhs	12.5-25 mg po bid or qhs	2 mg	10 mg	10 mg every 2-4 weeks
Titration schedule	Increase by 0.25-0.5mg every 2-4 weeks	Increase by 2.5 mg every 2-4 weeks	Increase by 25-50 mg every 2-4 weeks	Increase by 2 mg every 2-4 weeks	15 mg po qhs	25 mg every 2-4 week
Maximum dose	2 mg	10 mg	200 mg	10 mg	40 mg (for age 65+ max daily recommended dose is 20 mg)	150 mg
Side-effects	All antipsychotics can cause - sedation - falls, orthostatic hypotension - weight gain - impaired glucose tolerance - dyslipdemia	See Respiridone	See Respiridone	See Respiridone	All SSRIs can cause HANDS - Headache - Anorexia - Nausea - Diarrhea - Sleep problems Increased risk of bleeding Monitor for hyponatremia	Highly sedating Orthostatic hypertension Rarely may cause hypotension
Monitoring	Fasting lipids and glucose, gait, extra pyramidal symptoms
Special notes	Most likely to cause extrapyramidal side-effects, especially at higher doses. Increased risk of mortality and possibly stroke with all atypical antipsychotics.	Most likely to cause weight gain and metabolic side effects Fewer extrapyramidal side effects than respiridone More sedating than respiridone	Very sedating Least likely to cause extrapyramidal side-effects, should be used first in Parkinson's and Lewy body dementia	May be more likely to cause akathisia, less likely to cause weight gain	Emerging evidence suggests it may be as effective as antipsychotics Also effective in treating behaviours associated with frontotemporal dementia	Usually in treatment of sleep disturbance associated with dementia

All atypical antipsychotics (risperidone, olanzapine, quetiapine) are associated with an increased risk of mortality in older adults with dementia. This increased risk in studies was approximately one per cent greater than that observed with placebo. There is a similar increased risk of stroke in older adults with dementia treated with antipsychotics.

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Atypical Antipsychotics

Other Medications

General Principles of Pharmacotherapy