One of the greatest challenges, when it comes to Alzheimer’s disease and other dementias, is coping with sundowning and with difficult behaviors.
These are symptoms beyond the chronic memory/thinking problems that are the hallmark of dementia. They include problems like:
- Delusions, false accusations, paranoid behaviors, or irrational beliefs
- Agitation (getting “amped up” or “revved up”) and/or aggressive behavior
- Restless pacing or wandering
- Disinhibited behaviors, which means saying or doing socially inappropriate things
- Sleep disturbances
These are technically called “neuropsychiatric” symptoms, but regular people might refer to them as “acting crazy” symptoms. Or even “crazy-making” symptoms, as they do tend to drive family caregivers a bit nuts.
And when these behaviors happen in the late afternoon or early evening, it’s usually called “sundowning“. (In most cases, sundowning is triggered by fatigue; anticholinergic medications may cause sundowning symptoms as well.)
Because these behaviors are difficult and stressful for caregivers — and often for the person with dementia — people often ask if any medications can help.
The short answer is “Maybe.”
A better answer is “Maybe, but there will be side-effects and other significant risks to consider, and we need to first attempt non-drug ways to manage these behaviors.”
In fact, no medication is FDA-approved for the treatment of these types of behaviors in Alzheimer’s disease or other forms of dementia. (For more on the drugs that are FDA-approved to treat the cognitive symptoms of dementia, see here: 4 Medications to Treat Alzheimer’s & Other Dementias: How They Work & FAQs.)
But it is VERY common for medications — especially antipsychotics — to be prescribed “off-label” for this purpose.
This is sometimes described as a “chemical restraint” (as opposed to tying people to a chair, which is a “physical restraint”). In many cases, antipsychotics and other tranquilizing medications can certainly calm the behaviors. But they can have significant side-effects and risks, which are often not explained to families.
Worst of all, they are often prescribed prematurely, or in excessive doses, without caregivers and doctors first putting in some time to figure out what is triggering the behavior, and what non-drug approaches might help.
For this reason, in 2013 the American Geriatrics Society made the following recommendation as part of its Choosing Wisely campaign: “Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.”
You may now be wondering what should be the first choice. This depends on the situation, but generally, the first choice to treat difficult behaviors or sundowning is NOT medication. (A possible exception: geriatricians do often consider medication to treat pain or constipation, as these are common triggers for difficult behavior.)
Instead, medications should be used after non-drug management approaches have been tried, or at least in combination with non-drug approaches. (Learn about these here: 7 Steps to Managing Difficult Dementia Behaviors Safely & Without Medications.)
Of course in certain situations, medication should be considered. If your family member has Alzheimer’s or another dementia, I want you to be equipped to work with the doctors on sensible, judicious use of medication to manage difficult behaviors.
In this post, I’ll review the most common types of medications used to treat sundowning and difficult behaviors in dementia. I’ll also explain the approach that I take with these medications.
5 Types of Medication For Sundowning or Difficult Behaviors in Dementia
Most medications used to treat difficult behaviors fall into one of the following categories:
1. Antipsychotics. These are medications originally developed to treat schizophrenia and other illnesses featuring psychosis symptoms. (For more on psychosis, which is common in late-life, see 6 Causes of Paranoia in Aging & What to Do.)
Commonly used drugs: Antipsychotics often used in older adults include:
- Risperidone (brand name Risperdal)
- Quetiapine (brand name Seroquel)
- Olanzapine (brand name Zyprexa)
- Haloperidol (brand name Haldol)
- For a longer list of antipsychotics drugs, see this NIH page.
Newer antipsychotics include:
- Brexpiprazole (brand name Rexulti)
- This antipsychotic was initially FDA approved for the treatment of schizophrenia and as an adjunct for major depression.
- In May 2023, FDA approval was expanded to include the treatment of agitation associated with dementia due to Alzheimer’s disease.
- Pimavanserin (brand name Nuplazid).
- It was FDA-approved in 2016 for psychosis associated with Parkinson’s disease.
Usual effects: Most antipsychotics are sedating, and will calm agitation or aggression through these sedating effects. Antipsychotics may also reduce true psychosis symptoms, such as delusions, hallucinations, or paranoid beliefs, but it’s rare for them to completely correct these in people with dementia.
Risks of use: The risks of antipsychotics are related to how high the dose is, and include:
- Decreased cognitive function, and possible acceleration of cognitive decline
- Increased risk of falls
- Increased risk of stroke and of death; this has been estimated as an increased absolute risk of 1-4%
- A risk of side-effects known as “extrapyramidal symptoms,” which include stiffness and tremor similar to Parkinson’s disease, as well as a variety of other muscle coordination problems
- People with Lewy-body dementia or a history of Parkinsonism may be especially sensitive to antipsychotic side-effects; in such people, quetiapine (brand name Seroquel) is considered the safest choice
Evidence of clinical efficacy: Clinical trials often find a small improvement in symptoms. However, this is offset by frequent side-effects. Studies have also repeatedly found that using antipsychotics in older people with dementia is associated with a higher risk of stroke and of death.
2. Benzodiazepines. This is a “sedative/tranquilizer” category of medication that relaxes people fairly quickly. So these drugs are used for anxiety, for panic attacks, for sedation, and to treat insomnia. They can easily become habit-forming.
Commonly used drugs: In older adults, these include:
- Lorazepam (brand name Ativan)
- Temazepam (brand name Restoril)
- Diazepam (brand name Valium)
- Alprazolam (brand name Xanax)
- Clonazepam (brand name Klonopin)
Usual effects: In the brain, benzodiazepines act similarly to alcohol, and they usually cause relaxation and sedation. Benzodiazepines vary in how long they last in the body: alprazolam is considered short-acting whereas diazepam is very long-acting.
Risks of use: A major risk of these medications is that in people of all ages, they can easily cause both physical and psychological dependence. Additional risks that get worse in older adults include:
- Increased risk of falls
- Paradoxical agitation (some older adults become disinhibited or otherwise become more restless when given these drugs)
- Increased confusion
- Causing or worsening delirium
- Possible acceleration of cognitive decline
In older adults who take benzodiazepines regularly, there is also a risk of worsening dementia symptoms when the drug is reduced or tapered entirely off. This is because people can experience increased anxiety plus discomfort due to physical withdrawal, and this often worsens their thinking and behavior.
Stopping benzodiazepines suddenly can provoke life-threatening withdrawal symptoms, so medical supervision is mandatory when reducing this type of medication. (See How You Can Help Someone Stop Ativan for more information.)
Evidence of clinical efficacy: A recent review of clinical research concluded there is “limited evidence for clinical efficacy.” Although these drugs do have a noticeable effect when they are used, it’s not clear that they overall improve agitation and difficult behaviors in most people. It is also not clear that they work better than antipsychotics, for longer-term management of behavior problems.
3. Mood-stabilizers. These include medications otherwise used for seizures. They generally reduce the “excitability” of brain cells and other neurons.
Commonly used drugs: Valproic acid (brand name Depakote) is the most commonly used medication of this type, in older adults with dementia. It is available in short- and long-acting formulations.
Usual effects: The effect varies depending on the dose and the individual. It can be sedating.
Risks of use: Valproic acid requires periodic monitoring of blood levels. Even when the blood level is considered within an acceptable range, side-effects in older adults are common and include:
- Confusion or worsened thinking
- Dizziness
- Difficulty walking or balancing
- Tremor and development of other Parkinsonism symptoms
- Gastrointestinal symptoms including nausea, vomiting, and/or diarrhea
Evidence of clinical efficacy: A review of randomized trials of valproate for agitation in dementia found no evidence of clinical efficacy, and described the rate of adverse effects as “unacceptable.” Despite this, some geriatric psychiatrists and other experts feel that valproate works well to improve behavior in certain people with dementia.
4. Anti-depressants. Many of these have anti-anxiety benefits. However, they take weeks or even months to reach their full effect on depression or anxiety symptoms.
Commonly used drugs: Antidepressants often used in older people with dementia include:
- Selective serotonin reuptake inhibitor (SSRI) antidepressants:
- Citalopram, escitalopram, and sertraline (brand names Celexa, Lexapro, and Zoloft, respectively) are often used
- Paroxetine (brand name Paxil) is another often-used SSRI, but as it is much more anticholinergic than the other SSRIs, geriatricians would avoid this medication in a person with dementia
- Mirtazapine (brand name Remeron) is an antidepressant that can increase appetite and sometimes increases sleepiness when given at bedtime
- Trazodone (brand name Desyrel) is a weak antidepressant that is sedating and is often used at bedtime to help improve sleep
Usual effects: The effects of these medications on sundowning and on agitation is variable. SSRIs may help some individuals, but it usually takes weeks or longer to see an effect. For some people, a sedating antidepressant at bedtime can improve sleep and this may reduce daytime irritability.
Risks of use: The anti-depressants listed above are generally “well-tolerated” by older adults, especially when started at low doses and with slow increases as needed. Risks and side-effects include:
- Nausea and gastrointestinal distress, especially when first starting or increasing doses (SSRIs)
- SSRIs may be activating in some people, which can worsen agitation or insomnia
- Citalopram (in doses higher than 20mg/day) can increase the risk of sudden cardiac arrest due to arrhythmia
- An increased risk of falls, especially with the more sedating antidepressants
Evidence of clinical efficacy: A 2014 randomized trial found that citalopram provided a modest improvement in neuropsychiatric symptoms; however the dose used was 30mg/day, which has since been discouraged by the FDA. Otherwise, clinical studies suggest that antidepressants are not very effective for reducing agitation. (In fact, randomized trials find that antidepressants do not seem to improve depressive symptoms in people with Alzheimer’s disease.)
5. Dementia drugs. These are the drugs FDA-approved to treat the memory and thinking problems associated with Alzheimer’s disease. In some patients, they seem to help with certain neuropsychiatric symptoms, and they might help with sundowning. For more on the names of these drugs and how they work, see 4 Medications to Treat Alzheimer’s & Other Dementias.
Note: I am not including medications to manage dementia-related sleep disturbances in this post. You can learn more about those here: How to Manage Sleep Problems in Dementia.
If you’re wondering which medication is best for sundowning and difficult behaviors in dementia
You may be now wondering just how doctors are supposed to manage medications for difficult dementia behaviors.
Here are the key points that I usually share with families:
- Before resorting to medication: it’s essential to try to identify what is triggering/worsening the behavior, and it’s important to try non-drug approaches, including exercise.
- Be sure to consider treating possible pain or constipation, as these are easily overlooked in people with dementia. Geriatricians often try scheduling acetaminophen 2-3 times daily, since people with dementia may not be able to articulate their pain. We also titrate laxatives to aim for a soft bowel movement every 1-2 days.
- No type of medication has been clinically proven to improve sundowning for most people with dementia. If you try medication for this purpose, you should be prepared to do some trial-and-error, and it’s essential to carefully monitor how well the medication is working and what side-effects may be happening.
- Antipsychotics and benzodiazepines work fairly quickly, but most of the time they are working through sedation and chemical restraint. They tend to cloud thinking further. It is important to use the lowest possible dose of these medications.
- Benzodiazepines probably increase fall risk more than antipsychotics do, and are habit-forming. They are also less likely to help with hallucinations, delusions, and paranoias. For these reasons, if a faster-acting medication is needed, geriatricians usually prefer antipsychotics to benzodiazepines.
- Antidepressants take a while to work but are generally well-tolerated. They may not improve depressive symptoms, but they seem to make some people with dementia less irritable or anxious. Geriatricians often try escitalopram or citalopram in people with dementia.
- It is usually worth trying a dementia drug (such as a cholinesterase inhibitor or memantine) if the person is not already on these medications, as these drugs also tend to be well tolerated.
I admit that although studies find that non-drug methods are effective in improving dementia behaviors and to manage sundowning, it’s often challenging to implement them.
For people with dementia living at home, family caregivers or paid helpers often have limited time and energy to learn and practice behavior management techniques. Despite the risks of antipsychotics, family members are often anxious to get some relief as soon as possible.
As for residential facilities for people with Alzheimer’s and other dementias, they vary in how well their staff are trained in non-drug approaches.
What you can do about medications and difficult dementia behaviors
If your relative with dementia is not yet taking medications for sundowning and other difficult behaviors, consider these tips:
- Start keeping a journal and learn to identify triggers of difficult behaviors. You will need to observe the person carefully. Your journaling will come in handy later if you start medications, as this will help you monitor for benefits and side-effects.
- If the difficult behaviors really emerge or escalate in the late afternoon or evening, as is typical for sundowning, see if you can avoid fatigue or overstimulation by creating a routine that allows the person to rest quietly by mid-afternoon. You can find more tips to manage sundowning here.
- Learn to redirect and de-escalate difficult dementia behaviors. Contact your local Alzheimer’s Association chapter or local Area Agency on Aging to find support near you. You can also learn a good approach in this article: 7 Steps to Managing Difficult Dementia Behaviors (Safely & Without Medications)
- Ask your doctor to help assess for pain and/or constipation. Consider a trial of scheduled acetaminophen, and see if this helps. (For more on acetaminophen, see How to Choose the Safest Over-the-Counter Painkiller for Older Adults.)
- Consider the possibility of depression. It’s reasonable to consider a trial of escitalopram or a related antidepressant. That said, clinical research suggests antidepressants don’t work well in people with dementia. Research does suggest that in dementia, depression treatments involving certain types of therapy plus positive lifestyle changes is probably more effective than medication.
- If the person is often very agitated, aggressive, or paranoid, or if otherwise the behavioral symptoms are causing significant distress to the older person or to caregivers, it’s often reasonable to try an antipsychotic.
- Be sure to discuss the increased risk of stroke and death with the doctor and among family members. This can be a reasonable risk to accept, but it’s essential to be informed before proceeding.
- It’s best to start with the lowest dose possible.
- If there have been visual hallucinations or other signs of possible Lewy-Body dementia, quetiapine (brand name Seroquel) is usually the safest first choice to manage sundowning or other difficult behaviors.
- For all medications for dementia behaviors:
- Monitor carefully for evidence of improvement and for signs of side-effects.
- Doses should be increased a little bit at a time.
- Especially for antipsychotics, the goal is to find the minimum necessary dose to keep behavior manageable.
If your relative with dementia is currently taking medications for behaviors or for sundowning, then you will have to consider at least the following two issues.
One is whether the behavior issues currently seem manageable or not. If the behaviors are still often very difficult, then it’s important to look into triggers and other behavioral management approaches.
Ongoing agitation or difficult behaviors may also be a sign that the medication isn’t effective for your relative. So it may also be reasonable to consider a change in medication. The best is to work closely with a doctor AND a dementia behavior expert; some social workers and geriatric care managers are very good with dementia behaviors.
The other issue is to make sure you are aware of any risks or side-effects that the current medications may be causing.
The main side-effects I see people with dementia experience are excess drowsiness, excess confusion, and falls. These are usually due to high doses of antipsychotics and/or benzodiazepines. In such cases, it’s often possible to at least reduce the dosages somewhat. Addressing any other anticholinergic or brain-dampening medications can also help.
Now should you aim to get your relative completely off antipsychotics, in order to reduce mortality risk, improve alertness and thinking, and to reduce fall risk?
I have found that sometimes tapering people completely off antipsychotics is possible, but it can be a labor-intensive process. Furthermore, studies find that a certain number of people with dementia “relapse” after antipsychotics have been discontinued. Another very interesting 2016 study of antipsychotic review in nursing homes found that stopping antipsychotics tended to make behavior worse unless the nursing home also implemented “social interventions.”
In other words, attempting to completely stop antipsychotic medications involves effort, may be followed by worse behavior, and is less likely to succeed if you cannot concurrently provide an increase in beneficial social contact or exercise. It is certainly worth considering, but in people who are taking more than the starter dose of antipsychotic, it can be challenging.
No easy solutions but improvement IS usually possible
As many of you know, behavior problems are difficult in dementia in large part because there is usually no easy way to fix them.
Many — probably too many — older adults with Alzheimer’s and other dementias are being medicated for their sundowning or other behavior problems.
If your family is struggling with behavior problems, I know that reading this article will not quickly solve them.
But I hope this information will enable you to make more informed decisions. This way you’ll help ensure that any medications are used thoughtfully, in the lowest doses necessary, and in combination with non-drug dementia behavior management approaches.
To learn about non-drug management approaches, I recommend this article: 7 Steps to Managing Difficult Dementia Behaviors (Safely & Without Medications).
And if you are looking for a memory care facility, try to find out how many of their residents are being medicated for behavior or for sundowning. For people with Alzheimer’s and other dementias, it’s best to be cared for by people who don’t turn first to chemical restraints such as antipsychotics and benzodiazepines.
This article was first published in 2016, and was last updated by Dr. K in May 2023.
Robin says
Hi Leslie,
Thank you VERY MUCH for your expertise and helpfulness!
My 82 year old mother has dementia and very bad hearing. She’s progressed from IL to AL to memory care in an AL. She is very good with me when I bring her home for a few hours… We generally make lunch, go for a walk, listen to music, and maybe something else like fold laundry, plant herbs, polish silver… She is easy for me to manage 99% of the time. She thinks I’m her sister. I go with the flow. I’m happy if she’s happy. On the other hand, the director of the memory care unit has reported multiple instances of my mother exhibiting aggressiveness. Generally, it’s in response to my mother not getting her way. Either she won’t leave another resident’s room or she wants to do something in the kitchen that is “off limits”. When attempts are made to redirect, she can become physical, kicking a door, scratching a care giver, raising a fist… I’ve tried to give the director insight about my mother to try to help. She, and now the exec dir, say if I don’t get my mother on an antipsychotic drug ASAP to manage her, she will not be able to stay due to the risk of her hurting another resident or staff member. My mother is still quite strong. I’m torn between trying to move her to another community and trying a new drug. I like the staff at this community and it is very close to my home, but the memory care unit is very small and packed with residents who generally sit in one room with the tv on. Up to May, my mother had been drug-free. In May/June we began Gabapentin to try to stabilize her mood and reduce pain in her hip/knee/foot (hammer toe) and in July she began a low dose of Mirtazapine. Neither seem to be reducing aggressive behavior with staff. What do you think is a best next step? I see others and you mentioning Seroquel… Would a low dose of this be a best next solution? Haldol? Seroquel? I’m very distressed over the prospect of moving her and also over “dulling her out” with sedation, but have to find a solution right away before she hurts someone. Thank you, in advance, for your guidance.
Robin
Leslie Kernisan, MD MPH says
Sorry to hear of this dilemma regarding your mother. That is interesting that she is fairly manageable with you, but difficult at the facility.
It can be hard to know whether they are doing everything possible (or at least everything reasonable) to skillfully redirect your mother’s behavior and otherwise reduce her behaviors. Does she get enough stimulation? enough exercise? enough activity? Honestly, I am not sure how you could determine whether they are doing enough on the behavior management front. You could perhaps see if it’s possible to get a dementia behavior consultant to advise on your mother’s care, but you’d have to find one and perhaps pay out of pocket. You could also consider getting in touch with others who advocate for the rights of residents in facilities for your state, they sometimes have resources that can help you advocate more effectively. For instance, in California we have California Advocates for Nursing Home Reform. Every state also has a long-term care ombudsman. Lastly, you could see if it’s possible to connect with the family members of other residents in the memory unit, they might have ideas on how to assess the quality of care and negotiate with the facility.
In general, there is often a question of whether to be persistent and push the facility staff, versus not be “difficult” (which can offer your family certain advantages).
Re your mother’s pain, gabapentin is a second line anticonvulsant and in studies is mainly effective for neuropathic pain (pain related to nerves). It probably only helps 30-40% of people with such pain. So if pain is aggravating your mother’s behavior — which it might be — it’s possible that she still hasn’t been adequately treated for her pain. Also gabapentin can cause dizziness or sedation at higher doses. So you may want to talk to your mother’s doctor about re-evaluating her pain and trying something else. Most oral options and stronger analgesics do have risks, of course, but it still may be worth trying something at a lower dose, such as a half tablet of Vicodin. You could also ask if something topical might be an option, it depends on what seems to be the location and nature of her pain.
Re trying an antipsychotics, a second generation one such as Seroquel usually has a lower risk of certain side-effects, compared to Haldol. However all antipsychotics do raise the risk of death at least a bit, and increase fall risk.
Good luck!
Roxanne says
My father is 79 years of age. We have been dealing with dementia behaviors for about 3.5 years now. Unfortunately my dad is getting more verbally aggressive And threatening. We tried the ‘no medication’ route until this past June, when we agreed to citalopram to help with the increasing agitation. However his paranoia and confusion continues to increase. My mom is at her wits and and depressed. We are looking at starting seroquel, to see if that helps. My dad is in great shape still walks a half a mile each day with me, rides a bike and gardens, he is just completely not reality based, seeing people who aren’t there, asking about pets we dont have, and paranoid that people are stealng from him. We are doing our best to keep him at home for as long as possible, but i see my mom deteriorating caring for him, as he is very ornery and combative at times. Is our plan to add an antipsychotic at this point justified? Knowing the risks?
Leslie Kernisan, MD MPH says
Yikes, this sounds like a tough situation for all involved. I think you are quite right to be concerned for your mother’s welfare and agree that they need to be part of the weighing of pros and cons, as you consider your options for managing your father’s behaviors.
It is not ideal for antipsychotics to be used, but if you’ve tried all the safer options, then it might be reasonable to resort to antipsychotics, especially if that’s key to enabling your father to live at home or otherwise remain in a situation that overall serves him well.
What’s good is that you are doing this as a carefully considered decision. That is generally the best one can hope for: carefully considered decisions made after reviewing available options and being informed of the risks. Especially if your dad is having psychosis symptoms (e.g. delusions, hallucinations), the antipsychotic might help.
Otherwise, I would also encourage your family to look into other ways to relieve your mother’s caregiving strain. Some caregiving spouses are often reluctant to accept help in the home, or send their spouse to a day program, often because their spouse with dementia doesn’t want it. But many people with dementia eventually adapt and do well with the change, and it does help family caregivers sustain their efforts.
Good luck!
paul stein says
Excellent clarifying ethical documentation of “off label” psychotropic “chemical restraint” that is SOP in most NH’s that constitutes lots of complicated systemic historic ignorance about psychiatric pharmaceuticals and “elder abuse” etc. I have POA responsibilities for a 92 year old parent that has intervened many times with attending physicians, NH administrators, and staff regarding psychotropic Rx of her serious “dementia symptoms” greatly exacerbated by minimum dosage of Xanax, Depakote, and recent push to include Prozac I refused, coupled with lots of politicized systemic ignorance about patients rights and entitlements; the economics of promoted unquestioned pharmaceutical dependence; and overworked and underpaid staff etc. A little “critical psychological dialogue” helps. When I talk with my elder, who has no memory, about the “context” of her “symptoms” she knows exactly what I am talking about.
Leslie Kernisan, MD MPH says
Thanks for this comment. Your older parent is fortunate that you are so willing and able to advocate on his or her behalf!
JT says
Thank you so much for your help. I will look for a Geri-Psych Dr. to consult with in more detail.
JT says
P.S. She is also on Lithium for her Bipolar Disorder. She can’t increase the dose as her blood levels are already a little high for her age (within normal limits for non-geriatric patients.) Anti-Depressants have not been as successful in the past to treat her Bipolar Disorder as Lithium
Leslie Kernisan, MD MPH says
I guess another type of medication to talk to her doctors about would be other mood-stabilizers, such as the valproate. They have risks, but really all your available medication options will have risks.
JT says
My 68 year-old mother-in-law was diagnosed with Dementia in August of 2017. It was shocking to us as she had seemed “fine” just a two months earlier. She went from paying her own bills and making her own meals to being unable to toilet without cueing in just a few short weeks. She was hospitalized for very dangerous behavior in August of 2017 (she lived alone in a different state) such as: walking into oncoming traffic, walking while undressed and having delusions. She has had Bipolar Disorder for 45 years but never exhibited these symptoms. We had to put her in a memory care facility that same month as her wandering and constant need for help with ADLs was more than my husband and I could handle with two small children in the home. The hospital put her on an anti-psychotic (Risperidone) and it helped a lot. She was fairly happy and stable and was loved by all in her facility for about 6 months. (She did become completely incontinent–but, otherwise no changes in baseline.) But, in March we took her to a neuropsych specialist to try to determine the type of Dementia and he told her she had Alzheimer’s (We had kept that from her because we were afraid it would trigger her Bipolar Anxiety/Depression.) She obsessively thought about her diagnosis and seemed much more anxious. This same Neuropsych also believed she didn’t need to be on the anti-psychotic so we tried to slowly go off the medication. However, after just reducing the dosage from 1mg to .75 she took a dramatic change for the worse. She cut her wrists (her first suicide attempt) and was just a bundle of anxiety all the time. She forgot my kids names and my name. She also started some strange repetitive behaviors. We put the anti-psychotic back up to 1 mg but it didn’t help at all. Still, the doctors didn’t want to give her anti-anxiety medication. This week she made a second suicide attempt. (She said there was water running down her walls and they wouldn’t make it stop… clearly psychotic.) She is currently hospitalized. Would you give anti-anxiety medication in this scenario? The memory care facility doesn’t want to take her back because of liability reasons without anti-anxiety medications to sedate her. She is so miserable and anxious all the time it just seems cruel not to give her something to sedate her. What anti-anxiety medication would you recommend? She is very healthy other than the Dementia. No issues with walking although her balance is a little off. She will respond to questions but almost never initiates conversation. Ugh. I hate to put her on anti-psychotics and anti-anxiety medications but she is so miserable. The Hospital Dr wants to use a low dose of Valium but her NP wants Ativan. I don’t know which is right. Or, if we should try something else entirely like increasing the anti-psychotic.
Leslie Kernisan, MD MPH says
Yikes. Well, your mother sounds like a bit of a special case, with her situation sounding much more complicated than what I’d consider “garden variety” difficult dementia behaviors. Actually attempting suicide as a dementia patient strikes me as a bit unusual, but then again she has a past history of what sounds like significant mental illness.
Also she is relatively young for dementia, and I find those people often have either more severe progression of diseases such as Alzheimers, or less typical causes for their dementia symptoms. (Dementia in people over 85 is often due to a whole combination of things going mildly to moderately wrong in the brain, whereas in younger people it’s more likely due to one or two things in particular being very wrong.) For this reason, I think evaluation at a specialized memory center can be especially valuable for people her age.
In terms of her medications: these types of complicated situations are difficult for generalists to manage. Honestly, she would be best served by a geriatric psychiatrist or someone else who has particular experience managing mental illness in aging adults and dementia.
For most cases of dementia agitation, if chemical restraint seemed necessary and a person is already on antipsychotic, I’d probably prefer to try increasing the dose or otherwise working within that class, before adding a benzodiazepine. Antipsychotics are sedating, and also treat frank psychosis symptoms. Plus, it’s just generally better to have fewer different medications. But that’s a general principle, not a specific suggestion. In your mother’s case, it’s possible that her providers have good reasons to suggest a benzodiazepine. Valium is longer acting than Ativan. Generally, when starting something new, something not super long lasting is a more conservative/safe approach to take.
I hope you can find a specialist to assist you. Good luck!
Lyndsay says
Are you aware of research into Lyrica / Pregabilin for vascular dementia agitation. My mother was given this and it resulted in many side effects.The worst of which were a worsening of her cognitive abilities, greatly increased falls resulting in many injuries including broken vertebra, and head injuries, communication difficulties , worsened vision (she already had low vision due to MD, cataracts and no vision in one eye), itchiness and skin ulcers. She was kept on 150 mg of the medication despite my objection only reducing it to 100mcg after many serious falls. She has recently had another ‘unseen fall’ and now appears unable to walk although the injuries are apparently muscular and yet her doctor wants her to go on morphine for her pain which is present when she gets up or down or turns when transferring from chair to wheelchair or toilet. I have power of attorney but my views are ignored.
Leslie Kernisan, MD MPH says
I took a quick look in the medical literature via Pubmed; there is not much on using pregabalin for dementia agitation, mainly this trial
Impact of a stepwise protocol for treating pain on pain intensity in nursing home patients with dementia: A cluster randomized trial
Pregabalin is an anti-convulsant, and can be used to treat pain related to nerves. Dizziness and gait disturbances are known side-effects, so it’s quite possible that this medication increased her fall risk.
I am not sure why the health providers have continued to prescribe it over your objections. If you’re the designated power of attorney, then you should have the power to refuse certain treatments. If you feel you are being ignored, I would encourage you to bring this up with the clinicians, and with whomever may be supervising them or employing them, if necessary. It’s possible that they have good reasons for wanting your mother to be on these medications, but if so, they should be able to explain it to you, and they are supposed to be including you and your family’s preferences in the decision-making.
In geriatrics we do sometimes use opiates such as morphine, if we suspect that pain is a significant contributor to agitation. But normally we would only consider this after trying other approaches to managing the person’s pain, we would use the lowest doses possible, and we are also more likely go this route if maintaining comfort and quality of life is a major goal for the person’s medical care. It’s also essential to use laxatives when using opiates, because they are constipating and that’s distressing for the older person and can aggravate behavior.
Good luck!
Valerie McCamley says
Hello. I look after my husband who is 80. He takes Ebixa every day and the doctor prescribed quetiapina.
I have been giving half a tablet at night with success. Over the last ten days he doesn’t want to get out of bed. His appetite is poor and it’s a struggle to get him to drink.
I spoke to my doctor who prescribed haloperidol drops. 6 at night. I don’t know how to administer all of these meds. Can you please help me. My husband is very upset and afraid early evening.
Leslie Kernisan, MD MPH says
I had to look up Ebixa; looks like that’s the UK brand name of memantine, which is called Namenda in the US.
Quetiapine (brand name Seroquel) is an antipsychotic. All antipsychotics are at least somewhat sedating. As I explain in the article, we would normally use them as a very last resort for managing behaviors, and if the issue was sleep, we’d probably start by trying other approaches.
Haloperidol is also an antipsychotic. Normally we would not start a second antipsychotic while continuing a low dose of the first. You may want to ask the doctor if it’s necessary to use two, because generally it’s better to start by adjusting the dose of the first one. (Or if the person doesn’t tolerate it, switch to a different one.) If you aren’t sure how to administer the medications, I would recommend asking the doctor or a pharmacist. There are also sometimes caregiver education programs that can provide education on practical issues like how to administer medication.
Medications aside, it also sounds you’re concerned because he’s not getting out of bed and eating less over 10 days. For that problem, I would recommend a medical evaluation to check for a new or worsened health problem…there are any number of things that can cause an older person to lose energy or feel unwell. The initial evaluation can be done during an urgent care visit, and usually includes checking the blood count, blood electrolytes, considering a urine check, considering medication side-effects, and otherwise trying to determine if there’s a new problem with infection, heart, lungs, kidneys, brain, etc.
Good luck and take care!
Therese says
Hi Leslie, Thank you for your generous and patient replies. My 83-year-old father has been diagnosed with non-specific dementia and has gone from being a fit and active emeritus professor to someone who sits most of the day, reading the same things over and over. He has always had an explosive temper and been given to frequent temper tantrums so it is difficult to say if this is getting worse, but it is getting harder for my aging mother to cope with the outbursts. I guess we were hoping for a magic potion or ‘happy’ pill to provide some respite, but from reading your article it seems not.
Leslie Kernisan, MD MPH says
Sorry to hear of your father’s diagnosis, it must be heartbreaking to see him declining.
No, there’s generally no magic potion or happy pill. That said, a thoughtful multi-pronged approach can sometimes help. If feasible, getting him to exercise and otherwise get enough physical and social stimulation might help him be less reactive. The catch with social stimulation will be figuring out what activities (and in what amounts) provide the needed engagement without aggravating, overstimulating, or frustrating him. Many people with dementia enjoy music, some really respond to art therapy or other creative outlets.
You could also try talking to his doctors about whether citalopram might be worth trying.
Otherwise, I would encourage your family to keep thinking about how you can keep this manageable for your aging mother. This is much easier said than done, since many older spouses will initially rebuff their children’s attempts to get help, for a variety of reasons that I won’t go into now. But for some families, getting a paid person in to help on most days ends up making a big difference, since the caregiving spouse can take a few hours off, restore himself/herself a bit, and then have more patience with their spouse during the rest of the time.
It is definitely a process to learn about managing dementia behaviors and then since every person with dementia is different, it can take a while to figure out just what helps them and is feasible to provide. Your parents are lucky to have you trying to learn more, in order to help them.
I do recommend Paula Spencer Scott’s book, and she shares an approach to managing difficult behaviors in a related article:
7 behaviors.
Good luck!
Joy says
I have really enjoy your web site and as many others are searching for the right combination of drugs for my mother with Alzheimers. We had tried Risperidone and it did not work well so they switched to Seroquel. I feel it has made her more agitated at times and sedated. She recently was in the hospital after a fall and fractured C2 which was very challenging. We had her off antipsychotic prior to the fall and the facility felt she was easier to redirect off the med. During the hospital stay they gave her hallol, then zypresia and then seroquel. She reguired a sitter after starting these drugs. I keep wondering if there is any other meds, I have read about Depakote and Tegretol but our doctor only wants the Seroquel. What are your thoughts? After she left the hospital for the C2 we took her back to her facility and she fell a week later and broke her arm. I then took her home with me. I then found a great adult family home with an experienced caregiver but the first night mom “screamed”, to me she calls out loudly for a family member and then she did not want to get in the bed or eat. They felt they could not take her after one night so she is back with me. She has not been on any antipsychotic meds but doctor wants to start Seroquel again, which seemed to have a paradox effect to me. She has been a dream for me the last 36 hours. I did get her GP to let us give 1/2 of Trazadone at bedtime which has helped her sleep. Her only other dementia meds are the Memantine and Donepezil. Thanks for any advice.
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s difficulties.
Well, in general it is better for her to be on fewer medications, esp since antipsychotics and mood-stablizers, such as valproate (brand name Depakote) increase the fall risk and she has already had several falls! People with dementia are often more agitated during hospitalization, because it’s an unfamiliar environment plus they may have pain or other problems contributing to delirium and cognitive instability.
I cover valproate and mood stabilizers in the article.
If you can manage with trazodone, that is probably safer. You could also read the article on dementia and sleep, which has some suggestions: How to Manage Sleep Problems in Dementia
I do think it would help if everyone could give your mother some time to settle in somewhere. Good luck!