Be Careful When Using Medications to Manage Behavioral Problems
Behavioral problems like aggression, agitation, and hallucinations are common among those with memory loss and dementia. They are often treated with medications as a class called “antipsychotics” or “neuroleptics.” The newer medications in this class include Risperdal, Zyprexa, Geodon, Seroquel, and Abilify. Examples of older medications in this class of drugs include Thorazine, Haldol, and Melleril and are not widely used today. The newer medications are used in about 90% of prescriptions written.
The belief was that these newer (and more expensive) medications are safer and more effective than older medications. However, these assumptions have been challenged by recent research. The overall risk of death from use of these medications is low – about 3%. However these drugs affect heart rhythm and may cause a higher rate of sudden cardiac deaths in vulnerable individuals. This is true for individuals treated with either the older or the newer anti-psychotic medications. Not only did newer medications not offer any advantage over the older medications but the death rates were higher for higher doses of the drugs. Additionally, other recent research has shown that treatment with anti-psychotics (including newer medications) has been associated with weight grain, hyperglycemia (high blood sugars), increased risk for stroke and transient ischemic attacks (TIAs), pneumonia, movement disorders such as tardive dyskinesia, hyperlipidemia (high blood fats), and increased risk for metabolic syndrome. These findings are raising new questions about the relative benefits and costs of the newer as well as the older medications. The FDA now requires warning on the labeling for this class of medications.
When used in low doses (especially in the elderly) and monitored for safety, anti-psychotic medications have a role in management of severe behavioral problems in those with dementia. But these medications should be used with caution and vigilance and only if less problematic medications are tried first and don’t work. Careful cardiac evaluation needs to be done before and after prescribing these medications to better determine the risk versus the benefits of use. Blood sugars, lipids and weight should be monitored prior to and subsequent to prescribing these medications. Family members should be vigilant for over sedation or gait changes. The medications should be carefully discontinued when they are no longer needed. Long-term use should be considered only if the medication effectively helps manage the behavior they were prescribed to help (i.e., there is empirical evidence a treatment effect) and adds to quality of life.
Finally, medications should be used at the lowest dose possible and be only part of treatment. Difficult behaviors also need to be managed through environmental (e.g., keeping people with memory loss engaged) and behavioral control interventions (e.g., calming voice, redirection toward peaceful activity).
