Drugs Used To Relieve Behavioural And Psychological Symptoms
Behavioural and psychological symptoms are very common, usually developing as a persons dementia progresses and can often be successfully managed without medication.
Drugs for behavioural and psychological symptoms
People with dementia often develop changes as their condition progresses.
These include changes in their behaviour and feelings, the things they think and how they perceive the world. Collectively, these changes are referred to as behavioural and psychological symptoms.
They are often more distressing for the person with dementia, and those supporting them, than problems such as memory loss.
Prevalence Of Agitation In Dementia
Statistics vary, butsome research estimates that as high as 80% of people with dementia experience agitation. One study determined that approximately 68% of people with dementia who were living in the community experienced excessive agitation. Another study found that among people with dementia who were in nursing home care, approximately 75% of them experienced agitation.
Whats The Best Way To Manage Agitation Related To Dementia
You notice your loved one becoming more forgetful. She cannot recall her visit with her granddaughters yesterday. She claims she took her medications this morning, yet you find them untouched in her pill case. You wonder how this mild-mannered woman has become so angry, so quickly. She is often frightened now, disoriented, and unpredictable. Yet she still remembers every detail of your wedding day, the names of your four children, and how to play her favorite piano pieces. When you sing together, time temporarily stands still.
Your loved one received a diagnosis of Alzheimers disease. Nights are the hardest time for her. You worry about her safety when she wanders through the house. She almost broke the door last week; you can tell her arm still hurts when you bathe her. She resists and yells at you when you take her to the bathroom. She has started to show behavioral symptoms of dementia.
How Treatment For Agitation In Alzheimers Patients Is Evolving
Some of the most serious behavioural problem faced by caregivers of patients with Alzheimers disease and other dementias are agitation and aggression. Approximately 20 per cent of patients with Alzheimers display significant aggression and the prevalence is even higher in institutionalized patients.
When asked, caregivers note that aggression is the most serious problem they face as a caregiver . Aggression often occurs in the context of receiving personal care and is often directed at the caregiver. These behaviours can lead to serious physical harm to the caregiver and the patients themselves. Physical aggression has been shown to increase caregiver burden, increase the cost of care, increase the risk of institutionalization and most notably, increase mortality.
Drugs Included For Prn Use Evidence And Rationale
While the above sections describes steps the panel endorsed for sequential treatment of agitation and aggression in Alzheimers and mixed Alzheimers/vascular dementia, it was recognized that at times the regular treatments cannot offer adequate protection from the impact of these symptoms. Accordingly, the algorithm allows for the possibility of supplementing medication given in the main sequence with drugs to be given on a PRN basis. The main drug selected for this purpose was trazodone, with use of lorazepam considered acceptable in certain circumstances.
PRN drug 1: trazodone
PRN drug 2: lorazepam
Benzodiazepines -A receptor, benzodiazepine site) have been widely used as anxiolytic and sedative/hypnotic agents since their introduction 50 years ago . However, they have been associated with falls and fractures , and acute cognitive deficits, especially in the elderly . Benzodiazepines are also associated with tolerance and addiction. For these reasons the panel chose not to recommend benzodiazepines in the sequence of regular treatments. Nevertheless, it concluded that occasional use of the benzodiazepine lorazepam as a PRN drug was acceptable in cases of extreme agitation or aggression where behavioural interventions and trazodone are ineffective, or when brief stressful circumstances might exacerbate or induce agitation and aggression, for example, medical tests or dental procedures.
How Is Ect Administered
Electroconvulsive therapy involves the administration of electrical stimulation to the brain which causes a brief seizure. Before undergoing ECT, a patient is given general anesthesia and medication to relax their muscles. The seizure caused by ECT will typically last about 30 seconds to a minute.
After the seizure, the person wakens within a few minutes, and within an hour is usually able to resume normal activities, although some psychiatrists prohibit driving for 24 hours.
The number of ECT treatments will vary depending on someone’s diagnosis, overall condition, and response to the treatments.
What Are Some Treatment Options
Treatment includes an appropriate medical diagnosis, ruling out any physical condition , medication effects, or environmental problems. Non-drug treatments are initiated first and can include interventions like activities, music, aromatherapy, and exercise. One of the most effective non-drug treatments is teaching the caregiver to use behaviour modification techniques. If these treatments do not result in sufficient improvement, and there is suffering for the patient or the caregiver, or if the behaviours are potentially dangerous, drug therapies are then used.
Actions For Positive Changes
After ensuring there is no environmental trigger, medical causes or medication side effect contributing to the patient’s change in behavior, other interventions are often recommended. Treatments to decrease neuropsychiatric symptoms and improve the patient’s comfort and mood can be as simple as redirecting the patient’s focus, increasing social interaction, initiating enjoyable activities, and eliminating sources of conflict. Establishing routines and providing comforting stimulation, such as the patient’s favorite music or films, can be beneficial in decreasing agitation. Creating a daily schedule that is posted in the home, keeping window curtains open to ensure the patient is oriented to time of day, and scheduling regularly timed meals can increase the patient’s comfort and decrease the risk of disorientation and behavioral symptoms. As a caregiver, learning strategies to modify your style of interaction with patients to minimize neuropsychiatric symptoms may help decrease your own level of frustration and distress.
What Causes Agitation In Alzheimers Patients
Agitation and aggression have multiple causes including environmental stress, pain, hunger, noise, unmet physical and emotional needs. It is also likely caused by the direct effects of the biological features of the disease process including changes in specific brain areas, resulting from the pathology and brain chemicals associated with the disease.
Best Anti Anxiety Medication For Elderly With Dementia
People with dementia can be upset or get anxious quite easily. It is also normal for people with such a condition to be rather restless and have issues sleeping. This is why you find them pacing up and down.
Anxiety is an issue that makes such elderly patients not be able to handle the daily routines and they can become very harmful to their loved ones or their caregivers. The best anti-anxiety medication for elderly with dementia should be administered to help them cope.
One of the greatest triggers of anxiety in such patients is change. It may be because the routine changes, or she /he is in new surroundings, or that he/she is surrounded by new faces.
It may also be because of fatigue or fear. Anxiety can also be because of infections or other underlying medical issues. If such a thing happens to a loved one and you are not able to point out the reason for the issue, you should seek help from a doctor to establish the real cause.
Do Antidepressants Work In Dementia
Among older adults living with depression, those with cognitive impairment differ from those without cognitive impairment. Although data on antidepressant use in dementia is ambiguous, much of the current research suggests that antidepressants dont work well in people with dementia . This could be the result of changes to the brain that occur in dementia. Although many doctors prescribe antidepressants as a first-line treatment, guidelines do not suggest the routine treatment of depression and anxiety with antidepressants in people living with dementia. Even the best-tolerated antidepressants in older adults carry serious risks of falls, fractures, and drug interactions.
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.
Side-effects
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 .
A Review Of Treatment Options For Agitation And Psychosis Related To Dementia
The Compass Clinic, Orlando, Florida
CITATION:Shanley A. A review of treatment options for agitation and psychosis related to dementia. Consultant. 2020;60:15-17. doi:10.25270/con.2020.05.00008Received December 12, 2019. Accepted April 20, 2020.
DISCLOSURES:The author reports no relevant financial relationships.
CORRESPONDENCE:Anamaria Shanley, MSN, APRN-C, The Compass Clinic, 100 W Gore St, Ste 406, Orlando, FL 32806
Approximately 5.8 million Americans are living with Alzheimer disease .1 Dementia has various etiologies, many of them reversable. The irreversible causes of dementia are AD, Lewy body dementia , frontotemporal dementia , and vascular dementia .2 At any time throughout the course of the neurodegenerative process, aggression and agitation can manifest. In fact, 75% of persons with dementia will demonstrate symptoms of aggression, agitation, and psychosis , which can interfere with quality of life for the person and his or her family.3
CITALOPRAM
ESCITALOPRAM AND RISPERIDONE
FLUVOXAMINE AND RISPERIDONE
LITHIUM
PIMAVANSERIN
OTHER CONSIDERATIONS
Hopefully in the future, better options will be available for treating dementia-related psychosis and agitation that are associated with less significant adverse effects.5,10
REFERENCES:
Read: Communication In The Middle Stages Of The Dementia Journey
Always treat your loved one with respect. These feelings can help foster effective communication with someone with dementia. Even more importantly, continue to interact with your loved one with dignity. Although you may see behaviors that remind you of a child, your loved one is not a child. Guarding his or her dignity will prevent hurt feelings that lead to agitation.
The reality of your loved one with dementia may not agree with the reality that you see. But the feelings that he or she is experiencing is something you can both understand. Using Validation Theory in dementia care can improve your communication. You can agree with your loved ones perception of reality without lying. The easiest way to do this is to ask gentle questions about what they are telling you. When your loved one tells you that there is a strange man in her kitchen, you can validate the feeling behind it and ask questions. Even if that strange man is actually her husband.
Try saying, That must be frightening! Would you like me to go check why he is there?
Other bridging phrases are:
- It would be so lovely to do that.
Set your loved one up for success. Dementia causes damage to the brain which makes it difficult to express thoughts and perform tasks. The brain can be overstimulated by background noises, clutter, crowds, or lights. This overstimulation can bring on feelings of restlessness.
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Prevention Strategies For Home
Person-centered care is an operating system in healthcare, which considers the health practitioner and the patients as partners in achieving tailored care that meets patients’ needs in a unique way . In the PCC framework, the social and historical background, the personality, and the lifestyle of the patients are considered to promote a positive social environment, good compliance, and best outcomes for patients with dementia . The PCC approach is considered a successful option to prevent agitation in home-living and care home patients with dementia and reduce antipsychotic use . Nonetheless, not every PCC-based strategy is effective. For instance, the Dementia Care Mapping , which is based on patients’ systematic observations, has generated conflicting results. In contrast, the Managing Agitation and Raising Quality of Life intervention has failed to improve agitation prevention in care home settings.
Previous studies have indicated a role for boredom in the onset of physical agitation . Thus, activity-based strategies have been developed to prevent this condition. The application of combined stimuli has shown to be more effective than a single activity . However, the most effective activity was live socialization .
Data that emerged from other non-pharmacological approaches, such as acupuncture and electroconvulsive therapy, are mostly conflicting. Some ongoing trials could possibly clarify a potential role for these therapies .
Find The Dementia Care Regimen That Works For You
No instance of dementia is the same. Individuals react differently to the disease and the medication used to treat it. It can take time to create a combination of drug and behavioral treatments that work.
Many times, the best, most calming way to approach dementia is to find a comfortable, secure dementia care community. At The Cabana at Jensen Dunes, we know just how important a comfortable home is for individuals with dementia. Thats why weve designed our Florida memory care community to include all the comforts of home with the safety and security needed when dealing with dementia.
At The Cabana, youll find spacious hallways, relaxing routines and dementia care programs designed to help individuals with memory impairments engage and improve cognition. Youll also find highly trained staff that can help with medication management, ensuring your relative or friend takes their medication in the correct dose at the correct time every day.
For more information on memory care communities like The Cabana, or contact us online. Our team will be happy to answer your questions and help you learn more about how a comfortable home can work with dementia medication to improve the quality of life for the people you care about most.
What Can Be Done
Due to the fact that such behaviors can be rather stressful to those providing care and those who are ill, many people wonder if there are medications that can make things better and the answer can be given as may be.
When you are considering medications to use on an elderly person with dementia, you will have to also consider the side effects that may occur because there are many risks involved. It is therefore important to try anxiety treatment without medication.
It is however common for such patients to be given antipsychotics in such a case. This is chemical restraint. In most cases, tranquilizing medications such as the antipsychotics can help in calming the behaviors, but there are many risks and side effects that may occur.
Sometimes the medications can be prescribed prematurely, which is risky since they may be given in excess. It is important to first establish why the behavior is happening in the first place and consider non-drug options before anything else. It is therefore not recommended to give the drugs at first until the real issue behind the behavior has been established.
Seizures & Mood Stabilizers
Common Drugs Taken:
- Valproic acid
- Uses: May be used to treating aggression. Has a sedative effect on agitated physical and verbal behaviors.
- Risks and Side Effects: Confusion or worsened thinking, dizziness, difficulty walking or balancing, tremor and the development of other Parkinsonism symptoms, and gastrointestinal symptoms including nausea, vomiting, and/or diarrhea.
- Non-Drug Treatments: Identifying underlying causes, promoting physical and emotional comfort, and changing the environment.
Managing Symptoms Of Agitation
Agitation is reported in about 50% of patients with Alzheimers disease. Aggressive behavior, irritability, disinhibition, and emotional distress are some of the features of agitation. The cause of agitation in Alzheimers disease patients is unclear, but the imbalance in neurotransmitter levels and their impact on brain cell communication may play a role.
The patients healthcare team, along with a trained therapist or psychiatrist, can help them and their caregivers cope with agitation. Coping strategies include:
- Developing a routine for daily activities such as bathing, dressing, and eating.
- Reducing clutter and noise.
- Incorporating daily relaxation techniques such as breathing exercises, soothing music, or walks.
Drugs Affecting Noradrenergic Neurotransmission
Alpha-1 Adrenoceptor Inhibitor: Prazosin
Several findings indicated the robust association between noradrenergic depletion and AD . Postmortem studies revealed that the prefrontal cortex in patients with AD was characterized by a significant reduction in noradrenergic neurons , which may be associated with a poor cognitive performance as well as the onset of aggression . Postmortem studies also showed that the compensatory upregulation of postsynaptic alpha-1 adrenoceptor is linked with AD-related aggression . Therefore, it has been proposed that reducing the activity of the overstimulated postsynaptic alpha-1 adrenoceptors may alleviate the aggressive behavior .
Fig. 7
Agitation In Acute Medical Conditions: Differential Diagnosis With Dementia
In elderly patients, acute agitation can be the expression of a wide range of conditions, including medical, psychiatric, and substance-induced alterations .
Table 1. Differential diagnoses in case of dementia-related agitation and other conditions.
In addition to hyperkinetic delirium, which can also arise during the hospitalization of cognitively unimpaired older people , other acute neurological conditions, such as stroke , intracranial neoplastic masses or hemorrhages, meningitides, encephalitides, and head injuries, may generate agitation that can be the first or unique symptom of the underlying condition.
The ascertainment of a history of psychiatric illnesses is critical, as these conditions may often determine the onset of acute mental alterations, including agitated behavior .
Dementia Medications To Avoid
It is important to note that there are medications that can actually make dementia worse than it is. When dementia drugs are developed, they are meant to increase Choline levels, which is a chemical that is needed by brain cells to communicate with one another.
However, some drugs can decrease the levels of this chemical and end up worsening dementia and can result in agitation and confusion. They may also cause issues with urination, constipation and a dry mouth.
There are many ailments that can affect dementia patients and they need to be treated. The drugs may have a negative effect on the patient and so alternatives should be sought out.
Drugs Affecting Cholinergic Neurotransmission
Selective Muscarinic M4 Receptor Agonist: HTL0016878
Another promising example of compounds being developed for treating dementia-related psychosis and agitation/aggression is the selective muscarinic M4R agonist HTL0016878 . The muscarinic receptors are abundantly expressed in the cortex and hippocampus, the areas involved in cognitive and neurobehavioral functions . In animal models, nonselective M1R/M4R agonists improved psychotic behaviors and cognitive performance . These findings have been confirmed in muscarinic M4R-knockout mice, and thus, it has been suggested that M4R agonists represent an attractive molecular target for the development of novel antipsychotic agents . A first-in-class selective M4R agonist, HTL0016878, developed by Sosei Heptares for the treatment of neurobehavioral symptoms in patients with AD, has advanced to phase I clinical trials . This randomized, double-blind, placebo-controlled study evaluated the safety, pharmacokinetics, and pharmacodynamics of this compound in 106 healthy young volunteers as well as in elderly patients . The results have not been revealed yet.
Can Agitation In Alzheimers Patients Be Treated With Medication
Drug treatments for agitation and aggression are only modestly effective, and some of the most effective treatments are often associated with serious side effects, including an increased risk of stroke and death. Because of this, the clinical neuropharmacology laboratory at Sunnybrook Health Sciences Centre has been searching for safer and more effective therapies to treat agitation and aggression in Alzheimers disease.
For some time, cannabinoids have been suggested as a treatment for Alzheimers disease, given their anti-anxiety effects, and a tendency to reduce aggression in the general population. Pre-clinical studies have even suggested a potential benefit on the pathology of the disease, possibly due to their anti-inflammatory effects. Based on this background, our lab reviewed all of the literature that was previously published on cannabinoids and Alzheimers disease, and were amazed by how little evidence there was. At the present time there have been only a small number of studies, with less than 150 patients with Alzheimers disease included in clinical trials. Many of these studies had negative outcomes and were actually unable to show any benefit on agitation and aggression.
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 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.
Side-effects
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 nights sleep is necessary for either or both of them. The use of such drugs should be regularly reviewed by the doctor.
Assessment Scales For Agitation
Several assessment scales are currently available to investigate the presence and severity of agitation . The Agitated Behavior Scale assesses an agitated state’s occurrence and duration after brain injury. The scale’s primary purpose is to monitor behavioral changes after admission to a hospital ward . The Behavioral Activity Rating Scale is often used in clinical trials. According to this scale, patients are classified into seven different levels of agitation . The Overt Agitation Severity Scale offers a helpful approach to detect and rate agitation when spanning from anxiety to aggression . The Modified Overt Aggression Scale , a scale divided into four sections, examines the frequency and severity of aggressive episodes . Another easy-to-use tool is the Pittsburgh Agitation Scale , which measures the dementia-related agitation severity . The Agitated Behavior Mapping Instrument is a diagnostic scale that evaluates 14 different physical and verbal agitated behavior features. Finally, the Cohen-Mansfield Agitation Inventory is a frequency rating scale completed by caregivers .
A screening tool for delirium is the 4AT, in which a score higher than four indicates a high risk for delirium . However, the Confusion Assessment Method for the ICU is a more sensitive and specific assessment to diagnose a delirium state .
Environmental Causes Of Agitation
A person with dementia generally cannot handle uncertainty the way a healthy person can. This means that any change to his or her environment can cause the patient to become agitated. It is therefore important to make sure the patients environment is not too noisy, improperly heated, or poorly lit, as these factors can lead to increased agitation and other problems. It is also important to keep to a routine. The patient may become distressed if left along for too long or surrounded by too many people at once.
+ Best Dementia Anxiety Treatment Practices
There are multiple different approaches to the best dementia anxiety treatment practices that are crucial for an individual with the disease.
Anxiety is one of the behavioral conditions that many people with dementia experience.
Studies estimate that about 25%-70% of the dementia population showcases anxiety symptoms.