Non‐neuroleptic medications in the management of agitation in Alzheimer's disease and other dementia: A selective review

Abstract

SUMMARYBoth neuroleptic and non-neuroleptic medications are widely used to treat symptomatic behaviors in dementia patients. There is a substantial body of literature suggesting that neuroleptics are modestly effective in treating these symptoms, but the magnitude of their effect is limited. Non-neuroleptic medications such as anticonvulsants and antidepressants have been advocated as useful in treating certain symptoms but have not been as well studied. This article critically reviews the published evidence for the effectiveness of selected non-neuroleptic medications in treating behavioral symptoms in elderly dementia patients, especially those with possible Alzheimer's disease. The medications reviewed include lithium, b-adrenergic blockers, trazodone, carbamazepine, buspirone, 1-deprenyl, and serotonin uptake blockers, reflecting the point of view that pharmacological approaches to the problem of agitation in dementia have included a variety of psychotropic medications. Most of these medications were not tried specifically with Alzheimer's disease patients, however, but in patients with various organic mental syndromes. The literature consists almost entirely of clinical series and case reports, making interpretations of the efficacy of individual medications difficult. With the singular exception of the serotonin uptake blocker citalopram, the few placebo-controlled studies are of small sample sizes, showing at best very modest efficacy for the study medication. Despite their widespread use, there is very little published empirical evidence for the effectiveness of these novel treatments for treating behavioral symptoms in elderly dementia patients.KEY worms-Agitation, dementia, management, non-neuroleptic medications.Agitation and other symptomatic behaviors remain principal problems in the clinical management of elderly patients with Alzheimer's disease and other dementia. Disruptive symptoms such as agitation, outbursts, violence, sleep disturbance, motor restlessness, delusion, hallucinations and misidentifications each occur in approximately one-third of various AD patient samples, with the majority of patients showing at least one symptom (Leuchter and Spar, 1985;Mayeux et al., 1985a;Reisberg et al., 1987). Between 50 and 75% of AD patients show significant disruptive behavior at some time during their illness (Rovner et al., 1990;Rubin, 1987).The consequences of agitated behaviors in dementia patients-regardless of the etiology-

Recommendations for the Management of Behavioral and Psychological Symptoms of Dementia

“…137 The investigators attempted to reach an optimal carbamazepine dosage with target serum levels of 5-8 g/ml, similar to the suggested guidelines for the use of carbamazepine in elderly bipolar patients. 107 Global improvement was noted in 77% of carbamazepine-treated patients compared with 21% of those taking placebo, with positive changes in agitation and aggression. While side effects were more common in the carbamazepine-treated patients, there was only one dropout due to side effects.…”

“…Lithium carbonate has demonstrated poor effectiveness in the case reports published to date, 107 though low doses and serum levels may have acted to limit effectiveness. A small number of individual case reports have suggested a variety of hormonal treatments may be effective for sexually aggressive and disinhibited behaviors as well as agitation, including m e d r o x y p r o g e s t e r o n e , 1 8 7 conjugated estrogens, diethylstilbestrol, 188 cyproterone, 189 and leuprolide.…”

Transdermal estrogen patches for aggressive behavior in male patients with dementia: a randomized, controlled trial

“…The search for a safe alternative to neuroleptics or benzodiazepines has led to several trials in this area including the use of anticonvulsants, lithium, cognitive enhancers, antidepressants and beta-blockers (Gauthier et al, 2002;Rösler et al, 1998;Schneider and Sobin, 1991). Case reports and two small clinical trials have evaluated the use of estrogen to control aggressive behavior in both men and women with dementia (Kyomen et al, 2002;Shelton and Brooks, 1999).…”

A short‐term inpatient program for agitated demented nursing home residents

“…However, most pharmacologic agents have complex prescription rules requiring accurate longitudinal behavioral observation, and sometimes monitoring of plasma levels and cardiac functions. Moreover, even when correctly prescribed, psychotropic drugs only partially reduce disruptive behavior (Schneider and Sobin, 1991).…”