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When are medications used to treat agitation?

Sometimes it is impossible to help a person become calm, despite your best efforts at providing warmth and structure. Medication for agitation can help you avoid caregiver "burn out" and make it easier for a suffering person to respond to your efforts. The more severe the agitation, the more important it is to consider medication. It does not "cure" dementia or agitation, but can reduce the frequency and severity of agitated behavior.

Doctors who are experts in geriatrics, psychiatry, or neurology are familiar with all of the medications we will be discussing. It is important to understand that most of the research in this area has been done with one group of medications (the antipsychotics, described more fully below). However, doctors often need to use other types of medicine. For this reason, the authors of this article conducted a survey to find out about the entire range of treatment that experts find helpful. Some trial-and-error is often involved before finding the right medication, dose, and schedule---every treatment plan is "custom made." Although the doctor can help call the shots, it is a good idea for you to learn as much as you can about the various choices available in terms of their likely benefits and possible side effects. Ideally, you can become the doctor's partner, since you see the person more than anyone else and may be in the best position to know how a medication affects him or her.

Families sometimes fear that anti-agitation medicines will just sedate a person or make their confusion worse, or that they are shirking their responsibility by relying on medication. To the contrary, the careful use of medication can lessen agitation without unwanted sedation and make it more possible to care for and communicate with an ill person.

How are specific medications chosen for a person?

Experts choose different medications based on several factors:

Is the goal short-term or long-term? The goal of short-term or acute treatment is to calm the person down quickly during a crisis. This often calls for sedation to make the person somewhat drowsy for a few hours. On the other hand, since agitation is often persistent, the goal may be to find a long-term treatment that can be used for many weeks or months without causing unwanted sedation or harmful side effects. However, it may take several weeks for such a treatment to begin working. This delay can require a fair amount of patience on the part of caregivers as doses are slowly and carefully adjusted.

What other medical problems does the person have, and what other medicines is he or she already taking? General medical conditions cause a person to be more vulnerable to side effects of medications. Older people are often already taking several medicines and it is extremely important to avoid interactions if another drug is added. Also, particular diseases may make it difficult to use certain anti-agitation medications. For example, people with lung disease should avoid medicines that might slow down their breathing, whereas those who fall or are unsteady on their feet should avoid medicines that might affect coordination.

What types of agitation symptoms does the person have? In choosing a medication, it is also important to consider the types of agitation symptoms the person has. For example, some medicines that might be best if the main problem is psychosis, whereas others would be more appropriate if the main problem is anxiety or depression.

What medication strategies are used for different types of agitation?

Many kinds of medication can be used to treat agitation, depending on the person's main symptoms. Doses are almost always lower than used in younger persons, because our bodies eliminate drugs more slowly as we age and side effects are more likely. The experts' recommendations for broad treatment strategies are outlined in the Table below. Each type of medicine is discussed in detail in the sections that follow.

Antipsychotics

Examples include:

Conventional antipspychotics, such as haloperidol (Haldol)

Atypical antipsychotics, such as risperidone (Risperdal); olanzapine (Zyprexa); quetiapine (Seroquel); others are likely to be available in 1998.

Antipsychotic medications, also called neuroleptics, have been the mainstay for treating agitation for many years, both in clinical practice and in research studies. There are two kinds: conventional antipsychotics, which have been available for the past 40 years (11 conventional antipsychotics are on the market), and atypical antipsychotics, which have been widely used since the mid-1990s. Antipsychotics are effective against delusions, hallucinations, aggression, and sundowning. They act rapidly and can be sedating, which makes them useful in emergencies. Haloperidol can also be given by injection if the need is urgent. Conventional antipsychotics sometimes cause three kinds of neurological side effects: 1) muscle stiffness and tremor that resemble Parkinson's Disease; 2) a restless feeling called akasthesia that may make the person want to pace around even more; and 3) after high doses given for many months or years, involuntary movements of the mouth or hands called tardive dyskinesia. A reasonable dose of haloperidol to treat agitation while minimizing side effects is about 1--2 mg/day, often given at bedtime.

The newer atypical antipsychotics represent a potential advance because they are less likely to cause neurological side effects. For this reason, many experts in our recent survey prefer to use the atypical antipsychotics rather than conventional antipsychotics, especially for long-term treatment. Even though they cost more and are not always free of side effects, they may be preferable for many patients in the long run.

The atypical antipsychotics in widest use now are risperidone (Risperdal) and olanzapine (Zyprexa). Risperidone has been tested extensively in older patients with dementia and agitation and can be as effective as conventional antipsychotics and, at a low dose, is usually free of neurological side effects. Possible side effects of risperidone are sedation and dizziness when standing. Side effects can be minimized by starting with a low dose, 1 mg or less per day. Small amounts can be given either by breaking a scored pill or using a liquid form. Olanzapine can be somewhat more sedating than risperidone, but is a useful alternative, especially for a person who has had muscle stiffness on risperidone, which occasionally happens, or for someone who has Parkinson's Disease. The typical starting dose is a 2.5 mg pill at bedtime. Quetiapine (Seroquel) had just recently been introduced at the time we were writing this guide: other atypical antipsychotics are expected to be available soon and may prove useful as more is learned.

Antidepressants

The type of antidepressant most often recommended for older persons with dementia is medication from the group known as selective serotonin reuptake inhibitors (SSRIs). Most experts prefer one of these two agents:

Other antidepressant choices to consider for an older person with dementia are listed below in alphabetical order:

Clearly, there are many antidepressants to choose from. There is often a need to try several medications before finding the best one for an individual. It is important to be very patient, since it often takes several weeks to tell if a medicine is working. During the waiting period, you can sometimes help keep up a person’s spirits with activities, a day program, or a support group.

Among the antidepressants, sertraline or paroxetine is often chosen first because these antidepressants have few side effects (occasionally insomnia or nausea) and are usually safe to combine with other medications an older person is likely to be taking, They are given once a day (usually in the morning). If these do not work, an alternative can be chosen, tailored to the needs of the individual. For example, bupropion and venlafaxine tend to be energizing and might be chosen for someone who is very withdrawn or apathetic. Nefazodone is relatively calming and might be a good choice for someone with a great deal of anxiety. The tricylic antidepressants tend to have more troublesome side effects, such as dry mouth, constipation, and dizziness if a person stands up too quickly. However, when used by experienced doctors and carefully monitored, they are sometimes quite effective in severe depression.

People with depression can also have delusions, such as a fear that body organs are not working, that they have been abandoned by everyone, or that they have no more money (when in fact they have). Delusional depression can be life-threatening due to suicide, or because of refusal to eat and drink, which can cause severe weight loss and dehydration. Agitation and trouble sleeping are also often very prominent. Although these symptoms can be very upsetting to witness, there are effective treatments. Usually, the first strategy is to combine the antidepressant with an antipsychotic medication. If severe depression or delusional depression does not respond to medications, electroconvulsive therapy can be lifesaving. Although there are many negative myths surrounding shock treatment, it is very safe when given by experts and is an important tool for the severely depressed person who is in extreme suffering.

Antidepressants can also be used in conditions other than depression. Some antidepressants, especially the SSRIs, can help with anxiety. Tricyclics and SSRIs are also used for pain relief in arthritis and certain types of nerve pain if over-the-counter medicines like Tylenol or Advil haven’t worked. Trazodone, a relative of nefazodone, is sold as an antidepressant but is usually too sedating for this purpose; we discuss it later as a sleeping aide.

Divalproex (Depakote)

Divalproex is best known as a treatment for brain disorders, such as epilepsy and seizures, and as a mood stabilizer for bipolar disorder (manic-depressive illness). It can also help with behavioral symptoms in older persons with dementia, especially in a person showing aggression, anger, or hypersexual behavior. It is often combined with an antipsychotic. The side effects of divalproex are nausea and sedation, which can usually be controlled by starting at small doses, making gradual adjustments, and monitoring the level of medication in the bloodstream. A low to average final dose of divalproex is 250 mg two or three times a day.

Carbamazepine

Carbamazepine is another anti-seizure medication that is also sometimes used for agitation. It can lower blood counts, which need to be monitored.

Buspirone (Buspar)

Buspirone is an anti-anxiety medication that is not habit-forming and does not cause sedation. Buspirone is an excellent choice for someone who is very nervous or worried but does not have psychotic delusions. It is sometimes helpful for someone who gets angry too easily. It is also very safe to combine with other medications that an older person may be taking for general medical problems. Side effects of headache, dizziness, or nausea can occur if the dose is too strong; once in a while it can also cause overstimulation. Buspirone works gradually, and the dose usually needs to be adjusted over 2 to 6 weeks before beneficial effects can be judged. A typical starting dose is 5 to 7.5 mg twice a day, whereas a final dose may be 15 to 30 mg twice a day.

Trazodone (Desyrel)

Trazodone is a relatively safe, non-habit-forming medication that is technically considered to be an antidepressant, but is actually used more often simply to help the individual get a good night’s sleep. It is also a good short-term alternative treatment for anxiety or when a mild sedative is needed. It should be started in very small amounts at first and adjusted upward until the right dose is found, usually about 50 mg. To help with sleep it should be given about 1 hour before bedtime. Its effects usually last about 8 hours, so if it is being used to help with daytime agitation, it may need to be given two or three times a day. Its main side effect is drowsiness if the dose is too high. Other side effects include dizziness when standing up and, very rarely, painful erections of the penis in men. Nefazodone (Serzone), a new antidepressant related to trazodone, is sometimes used for similar purposes; it may have fewer side effects.

Benzodiazepines

Examples include:

Benzodiazepines are a group of about a dozen medications that cause sedation and can relieve anxiety. They are best used only in temporary situations—once in a while for sleep or for a daytime crisis of anxiety or agitation when someone needs to be calmed down quickly. In an emergency, benzodiazepines are sometimes combined with an antipsychotic; they can also be combined for a week or more with other medicines that may take longer to start working, such as divalproex.

The benzodiazepines listed above are preferred by experts for use in older people because they are cleared from the body relatively quickly. The effects of others, such as flurazepam (Dalmane) and clonazepam (Klonopin), can last 24 hours or longer; these longer-acting agents are usually best avoided because they may cause daytime sedation or falling. A typical dose of lorazepam is 0.5 mg; its effects last about 8 hours, so it is sometimes used two or three times over the course of a day for someone who is very agitated. Zolpidem, the effects of which last 6 to 8 hours, is usually given only to help sleep, at an average dose of 5 mg. Temazepam and oxazepam are good alternative choices that are cleared from the body relatively quickly. Benzodiazepines are habit-forming if used steadily for more than a few weeks; even single doses can cause unsteady gait and interfere with memory.

Because of the disadvantages of benzodiazepines, it is usually best to avoid using them for the long-term treatment of insomnia, anxiety, or agitation unless other choices have failed.

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