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.
Christine M Swalgin says
My grandmother fell in Dec 2021 and fractured her hip. She had some sundowners and signs of dementia over the last few years. That being said she was living on her own for the most part. This last year her struggles were more noticeable. After the hip surgery it has worsened markedly. She went to a rehab. They ignored a DTI on her heel. It eventually infected her leg. Went to hospital for a week. Leg was better, heel wound like a 1 or 2. Went to different rehab. Got on hospice because she is 101 yrs old. Her behavior is pretty bad. She has bitten numerous cnas. Thrown things. Destroyed clothing, her glasses (twice), broke a pen and painted herself with ink. Picked at her diaper and made a mess of it when n the floor. We (my mom and I ) are at the facility every day. We have advocated for her safety and well being. She is resistant to taking any pills, so she was getting 1mg of Ativan compound ,every 8 hours. Now 2mg every 8 hours. The heel wound went from 3 to a 4! They were not caring for her at all. The last week there has been a lot of issues with here getting the gel on time. Over last weekend either an LPN decide not to give her a dose or they rain out of the meds! Hot mess! Now this whole week has been horrible! We are beside ourselves trying to figure out what to do! Fo we go to anti depressants or something else. Do they come in gel. We know she is at the end of life but we want to keep everyone safe. She is so combative they have to hold her and then her thin skin rips. We have a great memory care facility near by that we reserved a room but they cannot take her until the heel can go from every 12 hour dressing with collagen, to 3x a week. What can we give her to calm her and keep her safe??
Nicole Didyk, MD says
I’m so sorry that your grandmother is struggling. I can understand wanting her to be calm and safe, and medications can help but they’re not the whole answer.
Lorazepam (Ativan) is a benzodiazepine, which is a sedative/hypnotic. It’s often used for anxiety and sleep, but side effects can include confusion, falls, and too much sleepiness. People can go into withdrawal as well if it is stopped suddenly. It can be given in various ways, which makes it convenient if someone doesn’t want to swallow pills.
As a geriatrician, when I’m asked to consult on an older adult with behaviour changes, I start by trying tp determine if there’s an unmet need or trigger for the person’s behaviour. Pain, constipation, urinary tract infection or urinary retention, fear, anxiety or a misinterpretation of the environment, can all be reasons for an older adult to respond with resistance or aggression. Uncovering and correcting those issues can be more effective and safer than medications.
The presence of family members and familiar objects can also be very helpful to calm a person, so it’s wonderful that you were able to visit your grandmother.
As you’ve pointed out, any prescribed medication needs to be given regularly and by the correct route. Antidepressants usually take 2 to 6 weeks to start working once the right dose is reached, so that might be a longer term solution. Some antidepressants can be given under the tongue or in liquid form.
If you can ask for a consultation from a geriatrician or geriatric team, that would probably be a big help. I hope your grandmother is more comfortable soon.
Niki Van hoorn says
hello, I am a 40 year old female but my ageing mother says i’m bullying her all the time, its not true.
my mother is 78 and living in retirement home. she is complaining that i am abusive towards her, its not true, over the last year mum’s memory is slowly getting worse, she barely recognises me. a creates such a problem that its embarrasing to take her out in public. she will she will also critisize me for my reaction to her bad behaviour that its imposiible to reason with her. sadly we lost my dad due to cancer 30 years ago and i’m thinking she is still traumatized from the event that she will now claim dads death is all my fault, dad passed away of bowel cancer 30 years ago from complications with not enough treatment back then what do do do now. please help.
Nicole Didyk, MD says
It sounds like your mom is experiencing some responsive behaviour of dementia. I made a video about that which you can watch here: https://youtu.be/o-pmHQdKzq0.
Some of her behaviour may be related to unresolved grief as you mention, but could also be more related to another unmet need. I’m sorry that you’re bearing the brunt of her verbal expressions, and remember that arguing back is rarely effective and can make things worse. If your mom has a family doctor, asking for a referral to a Geriatrician might be helpful. There may be medications that could help, and a Geriatric assessment might help determine the underlying issue.
Dr. K has recently published a book called: “When Your Aging Parent Needs Help: a geriatrician’s step-by-step guide to memory loss, resistance, safety worries, and more”. This is a practical guide to how to start helping an aging parent, even when you don’t know where to start. You can learn more here:/bhwa-education-and-support/helping-older-parents-membership-waitlist/ . The book can help you to set small goals and make progress towards helping your mom.
AH says
Hi – looking for advice on my 73-year old mother, who was diagnosed with Alzheimer’s about 8-9 years ago. She’s cared for by my 80-year old father. They just moved halfway across the country to be closer, and shortly after they moved she started declining rapidly after being pretty stable for several years. Now she keeps insisting her husband isn’t the man she married, and sometimes he is the man she married but she wants a divorce and she constantly is packing suitcases to try and leave him. She doesn’t have a local specialist yet. This has been occurring daily for about the last 2 weeks. She wakes up in a panic and then her symptoms calm down later in the day, but then she also has many complaints about mouth pain without a physiological cause that can get her worked up and miserable in the afternoons. Her new PCP prescribed a low dose of Seroquel which seemed to work, and now they’re trying an extended release version since her delusions and agitation are far worse in the morning and my dad was concerned about sedating effects of the original dose given too early in the day. So in this case, we are fairly certain that it’s the recent move and the new house (which has had contractors coming in and out working on things) that brought on the rapid decline. But what do we DO about it? She seems to hate the house and keeps calling her children to help her leave her husband and take her home, but then if we take her anywhere she almost immediately wants to get back to her husband (and he’s the right version of himself, until the next time the cycle starts). We’re all confused and overwhelmed and could use some advice. Do we just ride it out on the Seroquel for now? If her external environment calms down then are there other recommendations to try in conjunction or instead? Thanks in advance.
Nicole Didyk, MD says
I’m sorry that your mom is having trouble transitioning to a new home, and that can be typical in moderate to more advanced Alzheimer’s.
The move may have been a trigger, but it’s possible that she was already progressing before the relocation and now it’s more obvious with the closer proximity.
Medications like Seroquel are often used for the type of behaviours you describe, and they are tranquilizing anti-psychotics. We use them cautiously in older adults with dementia, and try not to use them long term. There’s really not a lot of scientific evidence that they’re very effective for responsive behaviours.
I made a YouTube video about responsive behaviours that might be helpful.
In the end, a person with dementia has a limited capacity to change their behaviour, and it’s more effective if the family and care partners can modify how they act around the person instead. This can work better with professional guidance – such as with a behavioural consultant if one is available in your region. A good start is to keep a record of what you observe. Patterns may become apparent, and can give you some clues about how to redirect and calm your mom.
I hope that with time, your family can get into a new routine and that your mom feels better.
Martha Bounds says
I have just read this info it was great! My sister now lives with me and dementia and is in my care. It answered so many questions I had about her meds and how to deal with memory loss and behavior. I would like to know how I can get a copy of this article I just read. It would really be great for me to have on hand. Thank you so much!! Oh my sister is 82
Nicole Didyk, MD says
Hi Martha and I’m so glad you enjoyed the article and found it helpful.
If you have access to a printer, you can print a version of the article directly from the website (or any article on the site). At the very bottom of the article is a little green icon of a printer on the left hand side. Clicking on that will take you to a printer-friendly version of the blog article.
You can also bookmark the page with the article you enjoy in your web browser, so that you can access it easily online.
Vicky Hoh says
Hi I am seeking advice for my mom who is 76 years old. She only started showing signs of forgetting things this year and last month she lost her money which she hid away. She was obsessed with finding her money and then she couldn’t sleep well. We noticed the change in her behaviour and consulted a mental health specialist. He told us that my mom is having depression as well as exhibiting early signs of dementia. He then prescribed the following medications for my mom for twp weeks. But I noticed that she has not improved at all but became worse. Prior to this she can function normally in taking care of herself but now she has difficulty in walking, shuffling instead and need our assistance in bathing her. I noticed that she is like in a daze and can’t talk clearly. I am thinking of removing her from the medications instead. Please advise on the medication that was prescribed for her and what should I do to help her? Risperdal 1mg x 3 times daily, For night : 1. Zydis 5mg+Apo-Lorazepam 1mg+3. Lexapro 10mg+4. Torpezil 10mg. Your advice is much appreciated. Tq
Nicole Didyk, MD says
I’m glad that your mom was able to get a mental health consultation, but the list of medications you provided is not one I would usually use in an older adult, at least not starting all at once.
The Lexapro is an antidepressant, and the zydis and risperdal are both antipsychotics, or major tranquilizers. They can cause side effects that mimic the symptoms of Parkinson’s disease, like slowing down, unsteadiness, and shuffling. Torpezil may be a form of donepezil, which is a dementia medication, and lorazepam is a benzodiazepine, which we usually try to avoid in older adults, because of the increased risk for falls and confusion.
It can be risky to stop medications without medical advice and supervision, but I would definitely encourage someone in your position to review the need for those medications with the doctor or pharmacist, and let them know what you’re observing in terms of side effects.
You might be interested in this article about depression in later life that we recently posted.
I hope your mom is feeling better soon.
Vicky Hoh says
Thanks for your reply as I find it helpful and gave me the information that I am seeking to help my mom get good care for her mental health.
Nancy James says
Hello. Very interesting to read. My sister is 76 years old. Never been sick. Dental Hygentist all her life. A couple years ago her memory was not so good. Her family took away her stressers, job, car, and gained Power Of Attorney. Which she was happy to sign over. Her husband had died of Leukemia years ago. She worked and had ownership of 5 properties, rentals, bank accounts. It was too much. Her newphew got POA and it took him a year to get all her finances in order. She went to a memory care place and did well and was social. But then she’s had to change places 4 times, and move back south. That was when she got agitated, angry, broke a glass and went after someone. That place kicked her out. Then another place took her and put her on some meds., Then THEY kicked her out. Sent her to in-patients psych. Meds were introduced but it was a short time stay. Now she is in long term pych. My nephew went to the team meeting and finally they gave him the Prelimainary Diagnosis (I am a Social Worker). I told my nephew, make sure you get her diagnosis as well as her medication regimum. Her preliminary is: Psyzoid – Affective Disorder with secondary diagnosis of dementia. That makes more sense. They are trying to stabilize her on meds which takes 8 weeks. But I want to be proactive — and know WHAT medication she is on for how long, has it been effective? I, myself, have had Major Depressive order and Generalized Anxiety Disorder forever. Only until CILATOPRAM (Celexca) was invented, have I been normal. No side effects. My family calls it my happy pill. I was also on Ativan for a few years, but got off that. As far as insomnia, I found TRAZADONE is the miracle for that. 150 MGS every night/ or every other night works if you immediately close your eyes. You get your deep remember RIM sleep and awake feeling great. TRAZADONE years ago was only for depression. But now is used for insomnia. It is not addicting, and the anti-depressant aspect is like 2 good things in one. I am leery of anti-psychotics for my sister. She’s never been on medicine her whole life. I agree with you, the stressors of being moved 6 times in one year can be a relative preceptor for her getting angry. Your overall impression is greatly appreciated. It sounds like my family has to be on these doctors ass’s every week, and monitor her psych meds and progress ourselves. I know slot about pharmacologyy, but my nephew has been the head of decision making. And if I call up and make waves, it might not be so good. They all day it’s private and the records are closed. But I’ve been in Clinical Work all my career and I can get the rights to my sister’s records through a simple court order or a petition., There’s all ways to do anything. At least my nephew finally was able to get a diagnosis out of these pychiatrists. There are medications which are miracles to Schizophrenic patients who live in the Community now. However Scidzoid/Affective medications are all over the place. I don’t want her knocked out on Thorizine or Haldol. Small doseages of a benzoyl like valium, or Zanax won’t damage her, and may relax her fears and anger. Anti-psychotics, they have all kinds of wacky side effects, torrents , change in speech patterns. TThank you for your time, doctor. We should really be on top of her chart every week — that’s what I’m getting from you. And her doseages should be LOW, LOW, LOW. Correct? Much appreciated for your help.
Nicole Didyk, MD says
Your sister is lucky to have such a concerned and proactive family!
It can be frustrating to get information about a family member’s medications, especially if the regimen is changing frequently, which can be the case if the person’s medical team is working to stabilize behaviour and other symptoms. You’re right that for some, benzodiazepines can be helpful, especially if there’s panic or sever anxiety attacks, but we do try to avoid them in older adults, because of the risks of falls and further cognitive decline. Dr. K has a good article about medications which you can check out here.
I hope you can work with your sister’s team to get her on the best medications and feeling more like herself. Thanks for sharing your story.
Linda Kline says
Dr K – My mother (87 with moderate/late Alzheimer’s taking Memantine) began taking low dose Lexapro for depression a couple years ago. She has been living with me for 3 years after breaking a hip, and delirium significantly exacerbated her Alzheimer’s while in the hospital. She was prescribed Trazodone when she was getting up all through the night, obsessed about wanting to go home to her mother’s house, and became verbally and physically aggressive about 4 months ago. Meds were started after ruling out any physical cause. About a month ago, she became increasingly aggressive and began going door to door trying to get out of the house. She did manage to get out a couple times (one time slipping through the rails in the ramp!) and fell for the first time in 3 years. Thankfully, she wasn’t hurt. Her Trazodone was increased to 100mg but behaviors continued. I decided to take her for testing again at Primary’s office and found out she had a UTI. Her behaviors drastically improved as the antibiotic worked its magic. Unfortunately she fell again a few days ago as she is quite groggy and unsteady when she gets up. After X-rays at the ER, she fell again in the middle of the night and ended up back at ER for stitches. She then needed repeat X-rays before seeing Orthopaedic as she had been unable to walk since the first fall. I had planned to contact the neurologist again to discuss decreasing the Trazodone due to increased falls and grogginess that had been lasting into the afternoon. I thought maybe the antibiotic had been the cause of trying to elope and aggression. It has only been a few days, and mom is now back to using her walker with someone walking next to her. For the past couple days, she has laughed and seemed more like her old self. Now I’m wondering if the meds just needed to stabilize or something. Any advice would be greatly appreciated. Thank you for all your helpful articles and support.
Jody says
Mom is 90, she started displaying signs of dementia 5 years ago. Initially we treated the depression and anxiety with Sertraline, very gradually increasing dose as needed. After a fall started Remeron in rehab. Working with Dr, we were at 50mg sertraline and 15mg Remeron. She was having increased frequent episodes of agitation, anger, delusions. We are very in tune to her physical state watching for UTI, constipation etc and we’ve learned to support her with words and objects (never try to change her reality, distract and assign a task etc). The past few weeks she became uncontrollable, broke the front door trying to get out etc. Dr stopped all
Meds and started 50mg seroquel, she’s calm, peaceful and although pretty “flat” emotionally and frequent naps she’s no longer in distress. It’s a trade off but her outbursts, anger etc were very distressing for her and us. My question is should I talk to Dr about lowering dose?
Nicole Didyk, MD says
It sounds like you’ve had a real journey with your mom’s symptoms, and that’s not uncommon with dementia.
We usually try to use medications like quetiapine for the shortest time possible, and at the lowest dose possible, but they’re sometimes needed for a person’s quality of life. In my practice, if a person with dementia has been stable on a dose of quetiapine for a few weeks or months, and there’s no other obvious treatable cause for the change in behaviour, I will often try to gently reduce the dose, or even stop it.
At the same time, we do try to see if there are any environmental changes or approaches that the caregiver can adopt that can reduce the triggers for the behaviour responses. If these approaches can be implemented, medications can be used at lower doses and sometimes not at all.
Okoh Joy says
My mum is 73. This is the second stroke,affected the brain,shouting disturbing the environment,the first one she head loss of memory,the second one the same,but with short,saying abstract things like she is travelling ,they should wait for her to enter the bus,such works.She has been given Risperidone,but still shouting,do not know what to do again or give to her,when she starts talking and shouting. I want to cry,please I need your help,the drug to give her again to calm down,thank you.
Nicole Didyk, MD says
That sounds like such a difficult situation, and one that is common in vascular dementia, which is caused by strokes. Often, when there are responsive behaviours in dementia, medications are the first thing we try, but they aren’t always the answer. Here’s an article about other strategies to try that might help.
Inie says
Hi Doctor,
I have been DX with mild frontal lobe atrophy and MCI 1 1/2 years ago @47 years old. I am currently taking 7.5mg of mirtazapine at night since insomnia was an issue. Now I am get a full night’s rest. Upon walking I am usually calm. Then about mid day I struggle with anxiety or agitation mixed with depression. I have been prescribed SSRIs, Depakote, Lamotrigine, Buspar which were either unsuccessful or the side effects were intolerable. Ativan .5mg is only thing that has worked for me but I take sparingly since I am fully aware of its dangers. Now my Dr. wants me to try Abilify but I’m terrified to even start it. But my symptoms seem to be increasing. Have you had any success stories with this med? Also does frontal lobe atrophy mean dementia? Any response is appreciate.
Nicole Didyk, MD says
First, frontal lobe atrophy would most likely be a finding on a brain imaging study, like an MRI. Atrophy essentially means shrinkage, and can be due to a number of causes: stroke, neurodegenerative disease, like frontotemporal dementia, or it could be present from birth. By itself, a finding of frontal lobe atrophy is not enough to diagnose dementia. The diagnosis of dementia requires a complete assessment of a person’s function and cognition, which is often performed by a Geriatrician, Psychiatrist or Neurologist.
Abilify, or aripiprazole, is an atypical neuroleptic (aka anti-psychotic, or tranquilizer). It can be used to treat delusions, hallucinations, and is also used in depression and bipolar disorder. I have used it with some success to augment antidepressants in older adults with depression, but as a Geriatrician I don’t treat those in a middle-aged age group in general.
When I have a patient who’s “terrified” of a drug, I usually recommend talking to a doctor, pharmacist, or other health professional about it, rather than looking on the internet.
Most of the time, medication for anxiety and depression can be very effective, but have more chance of working if they’re part of a larger management plan that might include exercise, behavioural therapy, mindfulness, good nutrition, and avoiding things that might be toxic to the brain, like alcohol and illicit drugs.