Most media coverage focuses on the treatment of memory loss in Alzheimer’s and other types of dementia. However, many people with dementia also experience secondary symptoms such as agitation and psychosis. These symptoms can be traumatic for both the individual and their family and friends, and can cause more functional decline than the memory loss itself. Research is also being done on how to treat these problems but this work often is not reported in the media.

Since there is no FDA-approved treatment for agitation and psychosis in dementia, doctors must resort to off-label medication use, relying on the “art” of pharmacology rather than science. Antipsychotic medications have often been used for the treatment of agitation and psychosis in dementia. The older “conventional” antipsychotics were initially used for their sedative effect and their effect on psychotic symptoms like hallucinations and paranoia. When the newer “atypical” antipsychotics appeared on the market, doctors were excited because they hoped they could treat the agitation and psychosis of dementia with less-sedating, safer medications. Sadly, studies showed that atypical antipsychotics were linked with a small but significant increase in the risk of death in patients with dementia and the FDA gave these medications a black box warning. After the warning, many doctors reverted to using the conventional antipsychotics which did not have such a warning.

Recently, we got more bad news on treatment of agitation and psychosis in dementia. A study was done to examine the cardiac risks of the conventional antipsychotics in older adults (>50 years old) and found that they had a moderate increase in risk of serious adverse cardiac effects compared with those taking the atypical antipsychotics*. Another study showed that treatment with atypical antipsychotics worsens decline in Alzheimer’s dementia **. So which is worse, conventional or atypical antipsychotics?

Some doctors will try to avoid treatment with antipsychotics by using other psychotropic medications like mood stabilizers. However, there is more bad news on this front as well. A study was done to see if divalproex sodium could be used to prevent worsening of agitation and cognitive decline in Alzheimer’s disease***. They found that after 2 years, treatment did not delay emergence of agitation or psychosis or slow cognitive or functional decline; and worse, treatment was associated with significant toxic side effects.

What’s a doctor to do? Until the FDA approves a treatment for agitation and psychosis in dementia, doctors will continue to do their best – treat the problem while trying to minimize side effects. Consultation with a geriatric psychiatrist or another doctor with extensive experience with these problems may be your best resource for this “art” of psychopharmacology.

* Mehta et al., Risk of serious cardiac adverse events in older adults using antipsychotic agents. American Journal of Geriatric Pharmacology 2011:9 (April):120-132

** Vigen et al., Cognitive effects of atypical antipsychotic medications in patients with Alzheimer’s disease : Outcomes from CATIE-AD. American Journal of Psychiatry 2011 : May 15 (epub ahead of print)

***Tariot et al., Chronic divalproex sodium to attenuate agitation and clinical progression of Alzheimer Disease. Archives of General Psychiatry 2011:68(8):853-861

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Cognitive Psychiatry of Chapel Hill
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