Drugs used to relieve behavioural & psychological symptoms of dementia
Avoid drugs unless they are really necessary
Before any of the drugs mentioned on this page are prescribed it is essential to ensure that the person with dementia is physically healthy, comfortable and well cared for.
Whenever possible, the person should be helped to lead an active life, with interesting and stimulating daily activities. Behavioural and psychological symptoms of dementia can often result from unreported pain, other illnesses, drug interactions and environmental factors.
It is important to address these factors in the first instance before resorting to medication. By minimising distress and agitation it is usually possible to avoid the use of drugs altogether. If, after trying non-drug treatments, drugs are considered to be necessary remember:
- All drugs have side-effects that may worsen symptoms. It is important to weigh the benefits against the likelihood of side effects when considering the use of drug treatments.
- Always ask the prescribing doctor (usually the GP) why the drug is being prescribed, what the side effects may be and what you should do if they occur.
- Don’t assume that a drug that has proved to be useful at one time will continue to be effective. Dementia is a degenerative condition. The chemistry and structure of the brain will change during the course of the illness.
- Many people with dementia take a number of different medications. Certain combinations of drugs may counteract each other or act to make memory and thinking worse. Remind your doctor if other medications are being taken.
- If a drug is prescribed, check with your doctor that there is a clear plan to review the medication and to stop it as soon as possible. There should be defined treatment goals and careful monitoring as well as a clear timeline for drug withdrawal. Usually a trial of stopping drugs is recommended after three months.
Drugs will be more effective if they are taken exactly as prescribed by the doctor, in the correct dose and monitored regularly for side-effects. If symptoms are difficult to control, the GP may refer to a specialist for further advice.
- Some drugs need to be taken regularly to have an effect – for example, antidepressants and antipsychotics (sometimes called major tranquillisers or neuroleptics). These drugs are not helpful when given on an ‘as needed basis’. Other drugs, such as hypnotics or anxiety-relieving drugs, may be more effective when taken on an as needed basis. This should only be done after discussion with the doctor.
- Do not expect immediate results. Benefits may take several weeks to appear, particularly with antidepressants and antipsychotics.
- Side-effects may occur early or late in the course of treatment – it is important that you ask the doctor what to expect.
- Side-effects are usually related to the dose given (i.e. higher doses are usually associated with a greater chance of side effects). The doctor will usually ‘start low and go slow’, gradually increasing the dose until the desired effects are achieved.
- Once treatment has been established it is important that it is reviewed regularly. Take all medications to clinic and hospital appointments.
- Remember that some of the drugs taken to control behavioural symptoms can be dangerous if accidentally taken in large quantities. Make sure medicines are kept safe and secure.
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Names of drugs
All drugs have at least two names – a generic name, which identifies the substance, and a proprietary (trade) name, which may vary depending upon the company that manufactured it. Generic names are used in this information sheet – at the end you will find a list of drugs in common use, giving both the generic and proprietary names.
Drugs for treating agitation, aggression and psychotic symptoms
Antipsychotics (also known as neuroleptics or major tranquillisers) are drugs that were originally developed to treat people with schizophrenia. The use of antipsychotics in people with dementia remains controversial and clinical trials are in progress to better determine their effectiveness.
Side-effects can include excessive sedation, dizziness, unsteadiness and symptoms that resemble those of Parkinson’s disease (shakiness, slowness and stiffness of the limbs). Some antipsychotics are particularly dangerous for people with dementia with Lewy bodies or Parkinson’s disease, being very likely to cause severe stiffness. Some studies have suggested that sudden death may be a rare complication of giving older antipsychotics to people with dementia with Lewy bodies or Parkinson’s disease. If such a person must be prescribed an antipsychotic, it should be done with the utmost care, under close supervision, and should be monitored regularly.
A new generation of antipsychotics called atypical antipsychotics may be less prone to produce troublesome side-effects. However, while there is some indication that atypical antipsychotics such as risperidone and olanzapine can be beneficial, it is important to balance the potential benefit against possible side effects, which may include increased risk of stroke and death.
Whichever drug is used, treatment with antipsychotics should be regularly reviewed and the dose reduced or the drug withdrawn if side effects become unacceptable. Excessive sedation with antipsychotics may reduce symptoms such as restlessness and aggression at the expense of reducing mobility and worsening confusion.
Some studies have suggested that antipsychotic use may be associated with faster cognitive decline in people with dementia, but this finding is controversial and not supported by some other research. What may occur is that mental function is slowed in people with dementia who take antipsychotics so that they appear to have deteriorated, though this deterioration may be reversible if the drug is ceased.
Anticonvulsant drugs, such as sodium valproate and carbamazepine, are sometimes also used to reduce aggression and agitation.
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Drugs for treating depression
Symptoms of depression are extremely common in dementia. In the early stages they are usually a reaction to the person’s awareness of their diagnosis. In the later stages of the illness, depression may also be the result of reduced chemical transmitter function in the brain. Simple non-drug interventions, such as an activity or exercise programme, can be very helpful. In addition, both types of depression can be treated with antidepressants, but care must be taken to ensure that this is done with the minimum of side-effects.
Antidepressants may be helpful not only in improving persistently low mood but also in controlling the irritability and rapid mood swings that often occur in dementia and following a stroke. Once started, the doctor will usually recommend prescribing antidepressant drugs for a period of at least six months. In order for them to be effective, it is important that they are taken regularly without missing any doses.
Improvement in mood typically takes two to three weeks or more to occur, whereas side-effects may appear within a few days of starting treatment.
Tricyclic antidepressants, such as amitriptyline, imipramine or dothiepin, which used to be widely used to treat depression, are likely to increase confusion in someone with dementia. They might also cause a dry mouth, blurred vision, constipation, difficulty in urination (especially in men) and dizziness on standing, which may lead to falls and injuries. For these reasons their use by all age groups is in decline and they are not recommended for use in people with Alzheimer’s disease except when they have found to be the only effective treatment for previous depressions in that individual.
Newer antidepressants are preferable as first line treatments for depression in dementia. Drugs such as fluoxetine, paroxetine, fluvoxamine, sertraline, citalopram and escitalopram (known as the selective serotonin re-uptake inhibitors) do not have the side-effects of tricyclics and are well tolerated by older people.
They can produce headaches and nausea, especially in the first week or two of treatment. There is very limited information about the use of other newer antidepressants such as mianserin, mirtazapine and venlafaxine in people with dementia. Moclobemide is well tolerated by people with dementia and was found to be helpful in one large study of individuals with depression and cognitive impairment.
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Drugs for treating anxiety
Anxiety states, accompanied by panic attacks and fearfulness may lead to demands for constant company and reassurance.
Short-lived periods of anxiety, for example in response to a stressful event, may be helped by a group of drugs known as benzodiazepines. Continuous treatment in excess of two to four weeks is not advisable because dependency can occur, making it difficult to stop the medication without withdrawal symptoms.
In addition, benzodiazepines are associated with a range of side-effects that make them particularly problematic for older people and should not be recommended other than for very short term use. Where an individual has used benzodiazepine drugs for a long period prior to the development of dementia withdrawal may be difficult, but the decision about whether to continue their use or to slowly reduce the dose should be addressed with the doctor treating the person with dementia.
There are many different benzodiazepines, some with a short duration of action, such as lorazepam and oxazepam, and some with longer action, such as chlordiazepoxide and diazepam. All of these drugs may cause excessive sedation, unsteadiness and a tendency to fall, and they may accentuate any confusion and memory deficits that are already present. The long term use of benzodiazepines for neuropsychiatric symptons is not recommended, but they have a limited role in the short term treatment of agitation in people with dementia (Woodward 2005).
Antipsychotics (see above) are often used for severe or persistent anxiety. If taken for long periods some of these drugs can produce a side-effect called tardive dyskinesia, which is recognised by persistent involuntary chewing movements and facial grimacing. This may be irreversible, but is more likely to disappear if it is recognised early and the medication causing the problem stopped.
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Drugs for treating sleep disturbance
Sleep disturbance, and in particular persistent wakefulness and night-time restlessness, can be distressing for the person with dementia and disturbing for carers. Many of the drugs commonly prescribed for people with dementia can cause excessive sedation during the day, leading to an inability to sleep at night. Increased stimulation and activity during the day can reduce the need for sleep-inducing medications (hypnotics) at night. Hypnotics are generally more helpful in getting people off to sleep at bedtime than they are at keeping people asleep throughout the whole of the night. They are usually taken 30 minutes to one hour before going to bed.
If excessive sedation is given at bedtime, the person may be unable to wake to go to the toilet and incontinence may occur, sometimes for the first time. If the person does wake up during the night despite sedation, increased confusion and unsteadiness may occur.
Hypnotics are often best used intermittently, rather than regularly, when the carer and person with dementia feel that a good night’s sleep is necessary for either or both of them. The use of such drugs should be regularly reviewed by the doctor.
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Cholinesterase inhibitors and other drugs
The new generation of cholinesterase inhibitor drugs (donepezil, galantamine and rivastigmine) were originally developed to improve memory and the ability to carry out day-to-day living activities in people with Alzheimer’s disease.
Evidence suggests that these drugs also have slight beneficial effects on behavioural symptoms, particularly apathy (lack of drive), mood and confidence, (and in people with dementia with Lewy bodies) delusions and hallucinations. Taking cholinesterase inhibitor drugs may therefore reduce the need for other forms of medication. However, in higher doses these cholinesterase inhibitor drugs may occasionally increase agitation and produce insomnia with nightmares.
Memantine is the most recent antidementia drug to be developed. It works in a different way to the anticholinesterase drugs and is the first drug approved for those in the middle to later stages of Alzheimer’s disease.
There is some evidence that memantine has a positive effect on mood, behaviour and agitation.
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Commonly prescribed drugs
This list includes the names of many (but not all) of the different medications available. New drugs are appearing all the time and you may need to ask your doctor what type of medication is being prescribed. The generic name is given first, followed by some of the common proprietary (trade) names.
Haloperidol (Haldol, Serenace)
Sulpiride (Dolmatil, Sulparex, Sulpitil)
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Citalopram (Cipramil, also Celapram, Ciazil, Talam, Talohexal)
Dothiepin (Prothiaden, also Dothep)
Doxepin (Sinequan, also Deptran)
Fluoxetine (Prozac, also Lovan, Auscap, Fluohexal, Fluoxebell, Zactin)
Fluvoxamine (Faverin, also Movax, Luvox, Voxam)
Imipramine (Tofranil, also Tolerade)
Mirtazipine (Avanza, Axit, Mirtazon, Remeron)
Paroxetine (Aropax, Paxtine, Oxetine)
Sertraline (Zoloft, Xydep, Eleva, Concorz)
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Lithium carbonate (Lithicarb, Quilonum)
Alprazolam (Xanax, also Alprax, Kalma, Zamahexal)
Diazepam (Valium also Antenex, Valpam, Ducene)
Oxazepam (Alepam, Serepax, Minelax)
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Chloral hydrate (Welldorm)
Nitrazepam (Mogadon also Alodorm)
Temazepam (Femaze, Temtabs, Normison)
Zopiclone (Imrest, Imovane)
Cholinergic and other drugs
Sodium valproate (Epilim also Valpro)
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What kinds of questions should you ask your doctor about any drug being prescribed?
- What are the potential benefits of taking this drug?
- How long before improvement may be noticed?
- What action should be taken if a dose is missed?
- What are the known side-effects?
- If there are side-effects, should the dosage be reduced or should the drug be stopped?
- If the drug is stopped suddenly, what happens?
- What drugs (prescription and over-the-counter) might interact with the medication?
- How might this drug affect other medical conditions?
- Are there any changes that should be reported immediately?
- How often will a visit to the doctor who prescribed the drug be needed?
- Is the drug available at a subsidised rate?
A range of books, videos, Help Sheets and Update Sheets are available through Alzheimer’s Australia in your State or Territory by contacting the National Dementia Helpline on 1800 100 500.
Information is taken from the Update Sheet 'Drugs used to relieve behavioural and
psychological symptoms of dementia' and is for infomation only. It does not represent an endorsement of any treatment by Alzheimer’s Australia.