Carbamazepine reduced aggression in a blinded, placebo-controlled study in nursing home patients. 43 Use of carbamazepine requires monitoring of hematologic and liver profiles, alters the metabolism of itself and other drugs, and is associated with dose-related sedation.
Lamotrigine (Lamictal) takes a long time to titrate but may help with nonpsychotic agitation and impulsivity; it is a relatively new drug, and there are limited data to support its use at this time in the elderly.
Gabapentin (Gabarone), in case reports at doses primarily from 600 to 1,200 mg/day, reduced behavioral and psychological problems of patients with dementia and with good renal clearance. 44 Some patients may experience tremors or oversedation.
Phenytoin (Dilantin) is not a good choice for behavioral problems because of unwanted effects on teeth, bones, and balance.
Levetiracetam (Keppra) may cause behavioral disturbances to emerge or worsen. 45
Emerging evidence suggests that all anticonvulsants may also be associated with an increased risk of depressive symptoms.
COGNITIVE ENHANCERS MAY IMPROVE BEHAVIOR
Acetylcholinesterase inhibitors may improve some behavioral symptoms of dementia. In an open-label retrospective trial, delusionality, irritability, anxiety, disinhibition, and agitation improved in some patients on these drugs. 46 Patients most likely to respond were those with the most impairment from these behaviors and those with depressive or apathetic symptoms. 46 A Cochrane review found a modest beneficial effect on behavior. 47
Acetylcholinesterase inhibitors may reduce symptoms of apathy. Additionally, they actually improve depressive symptoms in mild to moderate dementia independent of any effect on cognition. 48
Memantine (Namenda), approved for the treatment of moderate to severe dementia, may reduce the prevalence and incidence of agitation, particularly in more advanced dementia. 49
The cognitive enhancers all require several weeks for titration and are not helpful for the acute management of behavioral or depressive symptoms.
Beta-blockers50 and estrogen 51 have been studied as off-label, nonneuroleptic treatments for male aggression. Use of progesterone in men with inappropriate sexual behavior 52 may have benefit; further interventions are reviewed by Srinivasan and Weinberg. 53 These recommendations are based on small case series. In addition, the hormonal treatments may carry significant morbidity.
Sedative hypnotics were evaluated for sleep difficulties in demented patients in a meta-analysis by Glass et al, 54 who found adverse cognitive events, psychomotor events, and daytime fatigue more common (5, 2.6, and 3.8 times, respectively) in the sedative group than in the placebo group.
For agitation in delirium, haloperidol (Haldol) is preferable to benzodiazepines, based on studies from the 1970s. 55 Although benzodiazepines carry an indication for anxiety, newly prescribed benzodiazepines and those with a longer half-life are associated with hip fractures in older adults, 56 possibly from sedation.
WHAT TO DO FOR YOUR PATIENTS
The 84-year-old woman
For the 84-year-old woman who is keeping her son awake all night, recommend making the environment safe for her to wander, including placing a bolt on the doors leading to the basement and outdoors and moving the knives to an area that she cannot reach, to avoid accidents. Recommend that she be given things to do that are repetitive, such as folding towels and arranging drawers. Referring her to day care may improve socialization and increase physical activity during the day, possibly improving her sleep time at night.