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Dementia: Medications for Treating Behavioural and Psychological Symptoms

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  • Dementia: Medications for Treating Behavioural and Psychological Symptoms
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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.

Related

  • Psychiatry in Primary Care: A Concise Canadian Pocket Guide 2019

    Read More

  • Alzheimer's Disease or Dementia: Health Information for Your Patients

    Read More

  • Responding to Older Adults with Substance Use Mental Health, & Gambling Challenges

    Read More

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


  1. 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.

In Dementia:

  • The Primary Care Practitioner Role 
  • Screening & Assessment
    • Assessing dementia and cognitive impairment in the real world
    • Beyond cognition: Five areas to assess in dementia
  • Diagnosis
    • Differentiating Types of Dementia
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    • Medications for Treating Behavioural and Psychological Symptoms
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Managing Behaviours
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