Dementia: drugs used for behavioural problems
People with dementia commonly develop symptoms such as depression, restlessness,
aggression, psychosis (delusions and hallucinations) and difficulty sleeping at some point
during their illness. These symptoms can be relieved in many cases by the careful use of
medication. This page describes the different types of drug which may be prescribed.
Avoid drugs unless they are really necessary
Before any of the drugs mentioned in this information sheet are given to someone with
dementia, it is essential to ensure that the patient is physically healthy, comfortable
and well cared for. Whenever possible, the patient should be helped to lead an ac active
social life, with interesting and stimulating daily activities. Assistance with
orientation, encouraging normal behaviour and doing everything possible to avoid distress
and agitation will help to reduce the need for drug treatment.
If, after due consideration, drugs are considered necessary remember:
- All drugs have side-effects which may worsen the patient's symptoms.
- Always ask the prescribing doctor why the drug is being prescribed, what side-effects
may occur and what you should do if they become evident.
- Don't assume that a drug which is useful at first will continue to be effective.
Remember that the dementias are chronic degenerative diseases, in which brain cells die at
a rapid rate. As all the drugs mentioned rely on a normal number of functioning brain
cells for optimal activity, it is understandable that their duration of beneficial effect
is limited.
Drugs are most likely to be successful in relieving behavioural problems and mood
disorders if they are taken exactly as prescribed by the doctor, in the correct dose and
monitored regularly for side-effects. If symptoms are difficult to control the GP may
refer to a specialist for further advice.
- Some drugs need to be taken regularly to have an effect, e.g. antidepressants and major
tranquillisers. Others such as hypnotics or anxiety-relieving drugs may be more effective
when taken on an 'as needed' basis. This should only be done after discussion with the
doctor.
- Do not expect immediate results. Benefits may take several weeks to appear, particularly
with anti-depressants.
- Side-effects may occur early or late in the course of treatment - it is important that
you ask the doctor what to expect.
- Side-effects are usually related to the dose. The doctor will usually 'start low and
go slow', gradually increasing the dose until the desired effect is achieved.
- Once treatment has been established it is important that it is reviewed regularly. Take
all medications to all clinic and hospital appointments.
- Some of the drugs taken to control behavioural symptoms can be dangerous if taken in
large quantities. If this is a possibility they should be kept out of reach of the person
with dementia.
Names of drugs
All drugs have at least two names - a generic name which identifies the substance and a
proprietary (trade) name which may vary depending upon the company which has manufactured
it. Generic names are used in this leaflet - at the end you will find a list of drugs in
common use, giving both the generic and proprietary names.
Controlling agitation, aggression and psychotic symptoms
Major tranquillisers (also known as neuroleptics or anti-psychotics) are drugs which
were originally developed to treat younger patients with schizophrenia. They are
frequently prescribed to people with dementia for symptoms including agitation, delusions (disturbed thoughts and false
beliefs), hallucinations (seeing and
hearing things which are not there), sleep disturbance and aggression. Commonly used drugs include thioridazine and
haloperidol.
Very few clinical studies have been conducted to determine exactly how effective major
tranquillisers are in dementia, but probably only a limited number of people benefit and
then only for a relatively short period of time (weeks or months).
- Side-effects include excessive sedation, dizziness, unsteadiness and symptoms that
resemble those of Parkinson's disease (shakiness, slowness and stiffness of the limbs).
Patients with dementia with Lewy bodies are
particularly sensitive to the side-effects of major tranquillisers.
- A new generation of major tranquillisers may be less prone to produce troublesome
side-effects - these include sulpride, risperidone, olanzapine, and quetiapine.
- Whichever drug is used, treatment with major tranquillisers should be regularly reviewed
and the dose reduced or the drug withdrawn if side-effects become unacceptable. Your
doctor will often start with a very low dose and increase it gradually until the
desired effects are achieved.
- Excessive sedation with major tranquillisers may reduce symptoms such as restlessness,
aggression and wandering at the expense of reducing mobility, worsening confusion and
increasing dependency.
Symptoms of depression are extremely common in dementia. In the early stages they are
usually a reaction to the person's awareness of their failing performance and diagnosis.
In the later stages of illness, depression may also be due to reduced chemical transmitter
function in the brain.
Antidepressants
Both types of depression can be effectively treated with antidepressants, but care must
be taken to ensure that this is done so with the minimum of side-effects. Improvement in
mood typically takes two to three weeks or more to occur, whereas side-effects may appear
within a few days of starting treatment.
Side-effects
- Tricyclic antidepressants such as amitriptyline, imipramine or dothiepin, which are
commonly used to treat depression in younger people, are likely to increase confusion in
someone with dementia. They might also produce dry mouth, blurred vision, constipation,
difficulty in urination (especially in men) and dizziness on standing which may lead to
falls and injuries.
- Newer antidepressants are preferable as first line treatments of depression in dementia.
Lofepramine and trazodone are often taken at night when their sedative effects help with
sleep.
- Drugs such as fluoxetine, paroxetine, fluvoxamine, sertraline and citalopram (known as
the selective serotonin reuptake inhibitors) do not have the side-effects of tricyclics
and are well-tolerated by elderly people. They can produce headaches and nausea especially
in the first week or two of treatment.
- All antidepressants may be helpful not only in improving persistently low mood but also
in controlling the irritability and rapid mood swings (emotional lability) which often
occur in dementia and which are also seen following a stroke.
- Once started, the doctor will usually recommend prescribing antidepressant drugs for a
period of at least six months. In order for them to be effective, it is important that
they are taken regularly without missing any doses.
Anxiety states, accompanied by panic attacks and unreasonable fearfulness, frequently
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.
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, a tendency to fall, and
they may accentuate confusion and memory deficits that are already present.
- Major tranquillisers such as thioridazine or trifluoperazine are often used for severe
or persistent anxiety. If taken for long periods these drugs can produce an unsightly and
sometimes irreversible side-effect called tardive dyskinesia which is recognised by
persistent chewing movements and facial grimacing. Tardive dyskinesia is more likely to
reverse if it is recognised early and the offending medication stopped.
Sleep disturbance and in particular persistent nocturnal wakefulness and night-time
wandering, can be very disturbing for carers. Many of the drugs commonly prescribed for
people with dementia can cause excessive sedation during the day, leading to an in
inability to sleep at night. Increased stimulation during the day can reduce the need for
sleep inducing medications (hypnotics) at night.
- Hypnotics are generally more helpful in getting people off to sleep at bedtime than they
are at keeping people asleep throughout the whole of the night. They are usually taken 30
minutes to one hour before going to bed.
- Chlormethiazole is generally well- tolerated by elderly people, although some cannot
take it because it produces an unpleasant itching sensation in the nose. Benzodiazepines (see section on drugs for treating anxiety) such as temazepam are
frequently prescribed. Thioridazine is also sometimes used for night-time sedation (see major tranquillisers).
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 they do wake through the night despite sedation, increased
confusion and unsteadiness may occur.
- Hypnotics are often best used intermittently rather than regularly when the carer and
patient feel a good night's sleep is necessary for either or both of them. The use of such
drugs should be regularly reviewed by the doctor.
Drugs commonly prescribed for behavioural problems and mood disorders
This list includes the names of many (but not all) of the different
medications available. New drugs are appearing all of the time and you may need to ask the
doctor what type of medication is being prescribed. Newer drugs are marked*.
The generic name is given first, followed by some of the common proprietary (drug
company) names for that particular compound.
Major tranquillisers
Chlorpromazine (Largactil)
Clopenthixol (Clopixol)
Fluphenazine (Modecate)
Haloperidol (Haldol, Serance)
Olanzapine* (Zyprexa)
Promazine (Sparine)
Quetiapine* (Seroquel)
Risperidone* (Risperdal)
Sulpiride* (Dolmatil, Sulparex, Sulpatil)
Thioridazine (Melleril)
Trifluoroperazine (Stelazine)
Antidepressants
Amitryptiline (Lentizol, Tryptizol)
Amoxapine* (Asendis)
Citalopram* (Cipramil)
Dothiepin (Prothiaden)
Doxepin (Sinequan)
Fluoxetine* (Prozac)
Fluvoxamine* (Faverin)
Imipramine (Tofranil)
Lofepramine (Gamanil)
Mirtazipine* (Zispin)
Nefazodone* (Dutonin)
Nortyrptiline (Allegron)
Paroxetine* (Seroxat)
Reboxetine (Edronax)
Sertraline* (Lustral)
Venlafaxine* (Efexor)
Anxiety-relieving drugs
Alprazolam (Xanax)
Buspirone*(Buspar)
Chlordiazepoxide (Librium)
Diazepam (Valium)
Lorazepam (Ativan)
Oxazepam (Oxazepam)
Hypnotics
Chloral hydrate (Welldorm)
Chlormethiazole (Heminevrin)
Flurazepam (Dalmane)
Nitrazepam (Mogadon)
Temazepam (Normison)
Zopiclone* (Zimovane)
Zolpidem* (Stilnoct)
This information sheet was written by Ian McKeith, professor of old age psychiatry at
Newcastle General Hospital.
April 1998
Page Text supplied by The Alzheimer's Disease Society of Great Britain