Medications For Behavior Problems - The Search For Therapies: Alzheimers

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Medications for behavior problems

Brain damage influences the way people act and react. As comprehension falters, emotional and behavior problems can soar. When the environment seems too confusing and overwhelming, someone with Alzheimer's may become angry or even violent. Although no treatment can halt the cognitive deterioration of Alzheimer's, there are ways to diminish or even resolve some behavior problems. For example, simplifying the environment, establishing a routine that places minimal demands on the individual, and using simple management techniques have all proved effective (see "Techniques for living with someone with Alzheimer's disease").

Sometimes behavior disturbances are rooted in a medical problem. Agitation, for example, may signal physical discomfort. When an undesirable behavior appears suddenly or the person fails to respond to management techniques, he or she should be evaluated by a physician. Treatment of an underlying condition sometimes resolves what appeared to be solely a behavior problem. For example, relieving neck pain caused by arthritis might stop a person from wandering at night.

Behavior management alone is not always sufficient. In some cases, a physician may prescribe psychiatric medications. Try not to expect immediate results, because physicians usually begin with a low dose and increase it gradually. Care is required because psychiatric medications can produce serious side effects, particularly in older people.

In addition, some medications, such as antidepressants, must be given for several weeks before their benefits become apparent. Keep in mind that individual responses to these medications vary considerably. The same drug that helps one person may not be effective or may even worsen symptoms in another individual.

Three classes of drugs may be used to treat emotional and behavior problems: antidepressants, anti-anxiety drugs (also called minor tranquilizers), and antipsychotics (also called major tranquilizers or neuroleptics).

Antidepressants

In addition to relieving depression, antidepressants often enhance the social functioning of a person with Alzheimer's disease, as well as improve appetite and sleep and increase energy (see Table 4). But side effects can be a problem.

One of the most serious side effects is orthostatic hypotension, a sudden drop in blood pressure when the individual stands up, which is a common cause of fainting. This sudden drop in blood pressure not only increases the risk of falling and being injured but may also cause the heart rate to speed up, which can exacerbate heart problems. But this side effect is more common with tricyclic antidepressants than with the selective serotonin reuptake inhibitors (SSRIs).

Tricyclic antidepressants also have a sedating effect, which may be desirable at night, but not during the day. In addition, these drugs are anticholinergic — that is, they block acetylcholine, which is already at reduced levels in individuals with Alzheimer's — and can thus worsen cognitive function and cause delirium. Other side effects include dry mouth, constipation, difficulty urinating, blurred vision, and increased heart rate.

The SSRIs — including fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) — act on serotonin instead of acetylcholine. Unlike tricyclics, they rarely cause dry mouth, constipation, or dizziness. Nor do they disrupt the heart rhythm. However, in some people, they cause insomnia, nervousness, agitation, and irritability. Other side effects can include diarrhea, nausea, loss of appetite, weight loss, sweating, sexual problems, and headache. These side effects can often be eliminated if the dose is reduced.

Anti-anxiety drugs

Doctors are likely to prescribe anti-anxiety drugs for people with Alzheimer's disease who are anxious, restless, or agitated. Because they are also sedating, these medications often relieve sundowning and insomnia (see Table 5). Unlike antidepressants, anti-anxiety drugs exert their effects quickly, often within an hour. However, older people are especially sensitive to these drugs, and over time, toxic levels can accumulate in the body and cause serious reactions, including oversedation and loss of coordination.

To prevent these side effects, physicians favor anti-anxiety medications that have a relatively short duration and can be given in small doses at intervals during the day. People who experience only occasional anxious episodes can be given a fast-acting anti-anxiety drug as needed, rather than taking scheduled doses.

Antipsychotics

Antipsychotic drugs may be useful in managing behavior problems that result from delusions, hallucinations, paranoia, severe agitation, and hostility (see Table 6). Although a 2006 study in the New England Journal of Medicine found that these drugs were no more effective than placebo in calming people with Alzheimer's, and therefore questioned the wisdom of prescribing them, doctors continue to recommend antipsychotics in some cases, as they may help some people temporarily.

Within the first two months of therapy, a person may develop symptoms that mimic Parkinson's disease, including slowed movements, tremors, rigid muscles, a shuffling walk, drooling, and a masklike expression. These symptoms can be managed with an anti-Parkinson drug. High doses of antipsychotic drugs over a long period of time can cause tardive dyskinesia, involuntary writhing movements of the arms, legs, and tongue. Fortunately, this is uncommon at the doses used to treat dementia. And compared with older antipsychotic drugs, the newer ones are less likely to cause either Parkinsonian symptoms or tardive dyskinesia.

Some people have a paradoxical reaction to antipsychotics, that is, they become even more agitated and restless. A lower dosage, different medication, or the addition of an anti-Parkinson drug usually resolves this problem.

Last updated:	January 23, 2007