Pharmacologic treatments
Pharmacologic therapies should be used when nonpharmacologic approaches are unsuccessful, or when a patient is at imminent risk to harm themselves or others.
Antipsychotics. Although there is conflicting data regarding the use of antipsychotics in older adults, these agents are the most common pharmacologic treatment for patients with BPSD. Several studies examining the efficacy of antipsychotics for treating BPSD have demonstrated an increased risk of cerebrovascular events, including stroke and death due to any cause.8 While the use of antipsychotics increases the risk of mortality in older adults, the absolute risk is still low.9
Antipsychotics used to treat BPSD include:
- Risperidone is well studied in older adults and has shown benefit for treating aggression, agitation, and psychosis.10
- Quetiapine has a favorable adverse effects profile and may help improve sleep and reduce anxiety.10
- Olanzapine. Low-dose olanzapine has been modestly effective in decreasing agitation and aggression in patients with Alzheimer’s and vascular dementias.11
- Aripiprazole has shown modest benefit in treating psychosis and agitation in patients with dementia but may be associated with insomnia or activation symptoms at lower doses.10
- Ziprasidone. Case reports have found benefit with oral and injectable forms.12
Antidepressants. In the CitAD study, which was a placebo-controlled randomized trial, citalopram titrated to a target of 30 mg/d was found to be effective in reducing BPSD.13 However, QTc prolongation limits the use of citalopram. Sertraline was studied in 1 small, randomized trial against haloperidol but showed no additional benefit.14
Mood stabilizers. In a small, randomized trial, carbamazepine was helpful for patients with BPSD who were resistant to treatment with antipsychotics, with efficacy demonstrated over 6 weeks.15 No other mood stabilizers have had significant positive results in treating BPSD.16
Anxiolytic medications. Some research suggests that the occasional use of lorazepam, as necessary, is acceptable for patients with extreme agitation or aggression when behavioral interventions or sleep aids are ineffective.17 Various case reports and case series have suggested gabapentin may be effective for BPSD.18
Prazosin. In a small randomized placebo-controlled trial, the commonly used antihypertensive agent prazosin reduced agitation and aggression in patients with Alzheimer’s dementia, at doses from 1 to 6 mg/d.19 Postural hypotension, the main adverse effect associated with prazosin, can limit its use.
Trazodone. Some research suggests trazodone can reduce irritability and aggression in patients with Alzheimer’s disease.20
Dextromethorphan/quinidine. In a 10-week phase 2 randomized clinical trial of patients with probable Alzheimer’s disease dementia, combination dextromethorphan/quinidine reduced agitation and was generally well tolerated.21
For patients such as Mr. X who do not respond to multiple pharmacologic treatments, electroconvulsive therapy (ECT) may be an option.
Continue to: Because Mr. X does not respond...