Antipsychotics for Behavioral Disturbance in Dementia? A Clinical Conundrum

By Corbett Schimming, MD and Judith A. Neugroschl, MD | February 28, 2012

At the time this article was written, Dr Schimming was Assistant Professor of Psychiatry at Mount Sinai School of Medicine, New York. Dr Neugroschl is Assistant Professor of Psychiatry at Mount Sinai School of Medicine and Co-Director of the Education and Information Transfer Core of Mount Sinai’s Alzheimer’s Disease Research Center. The authors report no conflicts of interest concerning the subject matter of this article.

Multiple classes of medications besides antipsychotics have been used to try to address the behavioral symptoms of dementia. Antidepressants, including SSRIs and trazodone; anticonvulsants, such as gabapentin, lamotrigine(Drug information on lamotrigine), and valproic acid; and even the cholinesterase inhibitors and memantine(Drug information on memantine) have all been used with variable success.^27-30 Although there is no real evidence to support which intervention will be most helpful for which patient, a rational approach that involves identifying target symptoms and closely monitoring for efficacy and adverse effects should be employed. In general, mild or infrequent symptoms that are predictable (eg, “sundowning”) or those that can be treated “prn” can often be managed with low-dose trazodone or gabapentin(Drug information on gabapentin). Other, mild to moderate symptoms, particularly those with associated anxiety or depression, can be targeted with an initial trial of an SSRI.

If symptoms are severe, a trial of antipsychotic therapy is appropriate if other methods of treatment have been exhausted. The decision to use an antipsychotic is typically made when the anticipated benefit of such a trial outweighs the potential risks. This decision should always involve a discussion with the family or caregivers to assess the goals of care (eg, avoiding hospitalization or nursing home placement, managing severe aggression). It is important to have a sensitive and informed discussion with the family or caregivers, addressing the palliative nature of this intervention as well as the potential risks. Target symptoms should be identified, quantified (frequency and severity), and tracked, and the patient should be closely monitored for potential adverse effects (eg, with periodic ECGs to check the QT interval and with recommended metabolic tests).

With distressing symptoms so common, and treatments that are only modestly effective and yet potentially harmful, the conundrum of how best to help patients and families remains elusive.

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Antipsychotics for Behavioral Disturbance in Dementia? A Clinical Conundrum

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