Gary S. Moak, M.D.

Martha is an 89 year-old, frail woman, with moderate to severe Alzheimer’s disease who lives at home with her 92 year-old husband.  Every evening she becomes very agitated.  She thinks that her husband is an imposter who means to harm her, and she demands to be taken home to her real husband.  His efforts to calm her down and prevent her from leaving the house in the middle of the night make her violent.  The couple’s son took her to the hospital emergency department, where she was given lorazepam (Ativan), an antianxiety medication.  This made her groggy, more confused, and even more aggressive.   A geriatric psychiatrist recommended risperidone (Risperdal), an antipsychotic medication.  If Martha were your relative, would you feel comfortable about her taking this medication?

Antipsychotic medications have been used to treat psychiatric and behavioral complications of dementia for over forty years (see the article What is the Difference Between Alzheimer’s and Dementia?).  Use of antipsychotic medications to treat patients with dementia is both consistent with professional practice guidelines and within the standard of care.   The newer antipsychotic medications include risperidone (Risperdal), olanzepine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify).  Haloperidol (Haldol) is an older antipsychotic that still has important uses in geriatric psychiatry (see the article What is Delirium)

Recently, however, the use of antipsychotic medications to treat patients with dementia has become controversial.  Researchers have examined large amounts of data from dozens of studies of antipsychotic treatment of patients with dementia and discovered risks that had not been apparent previously.  It appears that antipsychotic medications raise the risk of strokes and death among patients with dementia. The Food and Drug Administration has issued warnings about these risks, and this process has called attention to the fact that treatment of psychiatric symptoms of dementia with antipsychotic medications is not an FDA-approved use.  Other research has raised doubts about the effectiveness of antipsychotic medications in the treatment of patients with dementia. Understandably, this situation has left many patients, families, and doctors highly concerned, and there have been suggestions that antipsychotic medications should not be used to treat demented patients.  The rest of this article will help you put this controversy into perspective.

First, let’s appreciate the degree of risk involved.  The analyses done suggest that use of antipsychotic medications by demented patients may double or triple the rate of transient ischemic attacks (TIA) and strokes (together referred to as cerebrovascular adverse events (CVAE) and double the rate of death.  Obviously, this is highly alarming.  But the actual rate of CVAE varies from less than one percent in some studies to up to three percent in others, and the rate of death averages 3.54%.

Second, doubts about the “across-the-board” effectiveness of antipsychotic medications for all behavioral symptoms of dementia may be too pessimistic.  Agitation is a mixed bag of symptoms that appear under a wide range of medical circumstances.  No one type of medication should be expected to be very effective.   More careful analyses of the available research reveals that antipsychotic medications are, in fact, effective for aggressiveness and delusions, two of the more compelling and urgent indications for treatment.  Moreover, research on antipsychotic medications for behavioral symptoms of dementia may underestimate the true effectiveness of these medications.   Dementia patients who enroll in clinical research are likely to be less severely disturbed than some of the patients seen in everyday practice who need treatment the most.  Since antipsychotic medications may work best in more severely affected individuals, clinical research may fail to detect the benefits that are often seen in actual clinical practice.   In other words, antipsychotic medications may not be very effective on average, but for the worst patients, especially those who are violent or delusional, they may work much better.

Certainly any increase, no matter how small, in devastating complications, such as stroke or death, should give pause about using antipsychotic medications.  It also seems clear that antipsychotic medications are prescribed more than they ought to be.  But severe delusions and violent behavior carry their own risks, which include deteriorating health, injury to the person with dementia or their caregiver, and death.  Severe psychiatric complications of dementia commonly necessitate hospitalization, and may result in avoidable institutionalization, or loss of an assisted living facility apartment or a nursing home bed.   The patients who need these medications really need them.  Their situations are desperate.  Families who experience the dire behavioral complications of dementia first hand usually accept the tradeoff between safety and quality of life.  They are grateful for the relief that antipsychotic medications sometimes provide.

Are there alternatives to antipsychotic medications?  Yes and no.  Other groups of medications are, in fact, prescribed.  These include benzodiazepines, anticonvulsants, and antidepressants.  Unfortunately, none has been studied as extensively as antipsychotic medications.  The scientific data that exists does not show that alternatives to antipsychotic medications are effective, and all have their own downsides. And keep in mind that none of these alternatives is approved for dementia.  As of 2009, there are no FDA-approved treatments for severe behavioral problems in patients with dementia. Thus, the objection that antipsychotic medications are not approved for dementia is disingenuous.  Anti-dementia drugs approved for Alzheimer’s disease (Aricept, Razadyne, Exelon, and Namenda) sometimes can be effective for milder agitation but rarely help the severe symptoms that necessitate antipsychotic medications.

Unfortunately, there are no perfect medicines.  All drugs have side effects, and some can be serious.  Severe behavioral complications of dementia represent a hugely burdensome problem that can make life unbearable. At least antipsychotic medications work well for some patients.

When behavioral complications of dementia necessitate treatment, reasonable efforts should be made to avoid prescribing antipsychotic medications.  Comprehensive medical evaluation should be conducted and efforts should be made to treat other conditions or discontinue other medications that might be contributing to the psychiatric symptoms.  Behavioral approaches ought to be attempted, for non-emergencies, whenever possible, before resorting to antipsychotic medication.  Unfortunately, behavioral approaches are not always feasible or effective.  In many cases, the resources are just not available. Antipsychotic medication only should be used for carefully selected patients based on comprehensive evaluation, and only when vigilant monitoring by a knowledgeable professional is assured.  Ongoing use should be limited to those patients who clearly improve and have few, in any, side effects.

Moak Center for Healthy Aging©

Updated February 2009