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Evidence-Based Reviews


Get creative to manage dementia-related behaviors

Heed ‘unspoken messages’ before weighing antipsychotics.

Vol. 5, No. 5 / May 2006

Mrs. A, age 82, has advanced Alzheimer’s disease and has resided in a nursing home for 2 years. She does not recognize that she lives in a nursing home and waits by the door for her son to take her home. She spends her days weeping, telling visitors and staff she has been abandoned and must go home to care for her children.

Recently she has been wandering from the facility. When staff attempt to direct her away from the door, she resists, becomes physically aggressive, and hollers loudly. Her behavior bothers visitors and other patients, who frequently complain.

Her primary care physician prescribes a trial of olanzapine, 10 mg/d, but she becomes confused and suffers a fall. Staff report that Mrs. A is sleeping poorly and losing weight.

Deciding how to manage agitation, aggression, or psychotic symptoms of dementia is dicey at best. You can try an atypical antipsychotic despite the FDA’s black-box warning (Risks of using vs. not using atypical antipsychotics. Current Psychiatry 2005;4(8):14-28.

  • U.S. Food and Drug Administration. Center for Drug Evaluation and Research. Atypical antipsychotic drugs information. www.fda.gov/cder/drug/infopage/antipsychotics/default.htm
  • Drug brand names

    • Carbamazepine • Carbatrol
    • Donepezil • Aricept
    • Lorazepam • Ativan
    • Memantine • Namenda
    • Mirtazapine • Remeron
    • Olanzapine • Zyprexa
    • Oxazepam • Serax
    • Trazodone • Desyrel
    • Valproic acid • Depakote
    Disclosures

    The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

    References

    1. Alexopoulos GS, Jeste DV, Chung H, et al. The expert consensus guideline series: Treatment of dementia and its behavioral disturbances. Minneapolis, MN: McGraw-Hill; 2005.

    2. Schneider LS, Dagerman LS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. JAMA 2005;294:1934-43.

    3. FDA Talk Paper. FDA issues public health advisory for antipsychotic drugs used for treatment of behavioral disorders in elderly patients. U.S. Food and Drug Administration. Available at: http://www.fda.gov/bbs/topics/ANSWERS/2005/ANS01350.html. Accessed March 10, 2006.

    4. Treatment of agitation in older persons with dementia. The Expert Consensus Panel for Agitation in Dementia. Postgrad Med 1998;SPEC NO:1-88.

    5. Sutor B, Rummans TA, Smith GE. Assessment and management of behavioral disturbances in nursing home patients with dementia. Mayo Clin Proc 2001;76:540-50.

    6. McKeith IG, Dickson DW, Lowe J, et al. Diagnosis and management of dementia in Lewy bodies: Third report of the DLB consortium. Neurology 2005;65:1863-72.

    7. Feldman H, Lyketsos LD, Steinberg QM, et al. A 24-week, randomized, double-blind study of donepezil in moderate to severe Alzheimer’s disease. Arch Gen Psychiatry 2003;60:737-46.

    8. Sink KM, Holden KF, Yaffe K. Pharmacologic treatment of neuropsychiatric symptoms of dementia: A review of the evidence. JAMA 2005;293:596-608.

    9. Gauthier S, Wirth Y, Mobius HJ. Effects of memantine on behavioral symptoms in Alzheimer’s disease patients: An analysis of the Neuropsychiatric Inventory (NPI) data of two randomized controlled studies. Int J Geriatr Psychiatry 2005;20:259-62.

    10. Porsteinsson AP, Tariot PN, Jakimovich LJ, et al. Valproate therapy for agitation in dementia: Open-label extension of a double-blind trial. Am J Geriatr Psychiatry 2003;11:434-40.

    11. Tariot PN, Raman R, Jakimovich L, et al. Divalproex sodium in nursing home residents with possible or probable Alzheimer’s disease complicated by agitation: A randomized controlled trial. Am J Geriatr Psychiatry 2005;13:942-9.

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