Drugs used to relieve behavioural and psychological symptoms in dementia
People with dementia may develop behavioural and psychological symptoms including restlessness, aggression, delusions, hallucinations, apathy and sleep disturbances. This factsheet looks at the different types of drugs that can be used to treat these symptoms if non-drug treatments have not worked. It explains when and how they should be prescribed and what the side-effects might be.
Other psychological symptoms that people with dementia may develop include depression and anxiety. For information about these symptoms and how they can be treated, see factsheet 444, Depression and anxiety.
Behavioural and psychological symptoms in dementia
Behavioural and psychological symptoms in dementia are very common and usually develop as the disease progresses. These symptoms can be distressing, both for the person themselves and the carer. For example delusions (believing things that are not true, such as that the carer is an impostor) may cause the person to feel angry and behave in a hostile way. Hallucinations (seeing or hearing things that aren't there, such as hearing voices) might make the person feel afraid.
If a person with dementia develops behavioural and psychological symptoms it is important to remember that they are not 'behaving badly' and are not to blame. The symptoms may be a direct result of changes in the chemicals of their brain, or be due to a general health problem, such as discomfort caused by hunger, thirst or infection. These symptoms can also be related to the care a person is receiving, their environment or social interactions.
There are a number of different ways that behavioural and psychological symptoms in dementia can be relieved. This factsheet explains the different types of drugs that can be used. It is, however, important to note that most behavioural and psychological symptoms improve within four weeks without the need for medication.
When should drugs be used to treat behavioural and psychological symptoms in dementia?
Before medication is considered, any person with dementia who develops behavioural and psychological symptoms should be offered an assessment by their GP at an early opportunity. This assessment should try to establish any possible underlying factors that may have triggered or may be aggravating the person's symptoms. It is important to ensure that the person with dementia is physically healthy, comfortable and well cared for. The person should also be helped to lead an active life, with interesting and stimulating daily activities. In this way it is often possible to avoid the use of drugs altogether.
Simple non-drug treatments, such as reminiscence therapy and social interaction, can also prevent the need for drugs. For example, research suggests that some symptoms can be reduced by just 10 minutes of one-to-one time each day. A recent study also demonstrated that recognising and treating pain can significantly reduce agitation and aggression in people with dementia. Other examples of treatments include aromatherapy, talking therapies, animal therapy, music and dance therapy and massage. According to guidance from the National Institute for Health and Clinical Excellence (NICE), non-drug treatments such as these should be used before medication is prescribed - unless the person with dementia or others are at risk of severe harm. If these approaches do not help the person and their symptoms are severe or distressing, medication may be necessary.
Drug treatments - general information
All drugs have at least two names: a generic name, which identifies the substance and a proprietary (trade) name, which may vary depending upon the company that manufactured it. (For example, Aricept is the trade name for the anti-Alzheimer's drug donepezil hydrochloride.) This factsheet uses generic names.
Immediate results should not be expected in people taking drugs for behavioural and psychological symptoms as any benefits may take several weeks to appear. Drugs may also stop working. This is because dementia is a degenerative condition, so the chemistry and structure of the brain will change during the course of the illness.
It is also important to be aware that all drugs have side-effects that may worsen symptoms. As side-effects are usually related to dose, the doctor may start with a low dose which will be gradually increased until the desired effects are achieved. Once treatment has begun it is important that it is regularly reviewed by the doctor. For antipsychotic drugs, this should be after six and/or twelve weeks.
Drugs should always be taken exactly as prescribed by the doctor and be kept safe and secure as they can be dangerous if accidently taken in large quantities.
Antipsychotic drugs (also known as neuroleptics or major tranquillisers) are a group of medications that are usually used to treat people with mental health conditions such as schizophrenia. They are also commonly prescribed for behavioural and psychological symptoms in dementia. This is because in some cases they can eliminate or reduce the intensity of psychotic symptoms, such as delusions and hallucinations, and can have a calming and sedative effect.
There are many antipsychotic drugs that are used to treat behavioural and psychological symptoms in dementia, although risperidone is the only one that is licensed for this use. Other antipsychotic drugs prescribed for people with dementia are done so 'off-licence'. This approach can only be taken if the doctor has good reason to do so and follows rules set out by the General Medical Council.
Who can antipsychotic drugs help?
Drug trials have shown that, for people with Alzheimer's disease, antipsychotic drugs can have a small but significant beneficial effect on aggression and, to a lesser extent, psychosis (delusions and hallucinations). These effects are seen when antipsychotic drugs are taken for a period of 6-12 weeks. The benefits of these drugs for other symptoms and when used for longer than 12 weeks are very limited.
Antipsychotic drugs may be prescribed for people with Alzheimer's disease, vascular dementia or mixed dementia. If a person with Lewy body dementia must be prescribed an antipsychotic drug, it should be done with the utmost care, under constant supervision, and should be regularly reviewed. This is because people with Lewy body dementia, who often have visual hallucinations, are at particular risk of severe adverse reactions.
For mild-to-moderate behavioural and psychological symptoms, NICE recommends that antipsychotic drugs should not be prescribed in the first instance. Non-drug treatments should be used before antipsychotics are considered.
People with severe behavioural and psychological symptoms may be offered antipsychotic drugs in the first instance, but only in certain, clearly defined circumstances. For example, there should be a full discussion with the person and their carers about the possible benefits and risks of treatment. Symptoms are considered severe if they are happening very frequently and causing a great deal of distress and risk to the person and others around them.
Issues associated with the use of antipsychotic drugs in people with dementia
Antipsychotic drugs help around half of the people with dementia who take them and can be an important part of their treatment. However, they can cause serious side-effects, especially when used for longer than 12 weeks. This is why all prescriptions should be monitored and stopped after 12 weeks, except in extreme circumstances. Drugs can be safely stopped after this period with no worsening of behavioural symptoms in most people. People should always consult their doctor first before they stop taking any medication.
Possible side-effects include:
- sedation (drowsiness)
- parkinsonism (shaking and unsteadiness)
- increased risk of infections
- increased risk of falls
- increased risk of blood clots
- increased risk of stroke
- worsening of other dementia symptoms
- increased risk of death.
It is important to consider that antipsychotic drugs may help reduce behavioural and psychological symptoms, but because of these side-effects, this may be at the expense of the person's quality of life.
There is evidence that people with dementia are being inappropriately prescribed antipsychotic drugs. For example, antipsychotic drugs are being prescribed for long periods of time and are being prescribed to treat mild behavioural and psychological symptoms. It is thought that around two-thirds of antipsychotic prescriptions are inappropriate. Alzheimer's Society would like to see these drugs used only when they are really needed. For information about our campaign on this issue, visit alzheimers.org.uk/antipsychotics
Antidepressants and anticonvulsants
Research suggests that drugs developed to treat depression (antidepressants) can also be an effective treatment for behavioural and psychological symptoms in dementia. Specifically, studies have shown that the antidepressant drugs sertraline and citalopram may help reduce agitation. Antidepressants may also treat apathy (when a person shows a general lack of interest and motivation), which is thought to be the most common behavioural change seen in people with Alzheimer's disease. In addition to this, some psychotic symptoms may respond to the use of antidepressants.
Anticonvulsant drugs are a group of medications that are usually used to treat epilepsy, but are sometimes used for symptoms of aggression and agitation in people with dementia. For example, there is some evidence to suggest that the drug carbamazepine can be effective for the treatment of aggression. However, this evidence is very limited. An anticonvulsant called valproate is sometimes used to control agitation in people with dementia but current evidence does not support its use, with a recent review suggesting that it produces no improvements.
There is currently a need for more evidence about the effectiveness and safety of antidepressants and anticonvulsants in the treatment of behavioural and psychological symptoms in dementia.
There is increasing evidence that for some people the anti-dementia drug memantine may be an effective treatment for behavioural and psychological symptoms in Alzheimer's disease. Memantine has the advantage of being a safe treatment, with other benefits for daily living and memory. Further research is still needed to confirm how effective memantine is in treating behavioural and psychological symptoms but the evidence shows it is more effective than using antidepressants or anticonvulsants.
The other anti-dementia drugs - donepezil, rivastigmine and galantamine - are known as cholinesterase inhibitors. Cholinesterase inhibitors, particularly rivastigmine and donepezil, may reduce the severity of some behavioural and psychological symptoms in dementia and help delay their onset. Cholinesterase inhibitors are especially effective in Lewy body dementia and dementia related to Parkinson's disease in treating agitation, apathy and psychotic symptoms.
According to NICE guidelines, people with Lewy body dementia should be offered cholinesterase inhibitor treatment only if their behavioural and psychological symptoms are causing them significant distress. People with Alzheimer's disease may also be offered cholinesterase inhibitor treatment for distressing behavioural and psychological symptoms. However, this is provided that non-drug approaches and antipsychotic drugs have already been tried and were ineffective, or they haven't been tried but are thought to be inappropriate. People with dementia that is entirely due to vascular disease and is not a mixed form (dementia that is caused by both vascular disease and Alzheimer's disease) should not be prescribed cholinesterase inhibitors for behavioural or psychological symptoms.
Drugs used to treat sleep disturbance
People with dementia often experience sleep disturbances including not being able to get to sleep and waking up throughout the night. Sleep disturbances may be made worse by many of the drugs commonly prescribed for people with dementia, which can cause nightmares and excessive day-time sedation, meaning that the person is less tired at night.
Increased stimulation during the day, avoiding daytime napping and avoiding caffeinated drinks late at night will help reduce sleep problems. If the person takes their dementia medication at night and they are having problems sleeping due to nightmares or vivid dreams, they should try taking their medication in the morning instead. Exercise and some complementary therapies, such as bright light therapy, might also be helpful (see factsheet 529, Exercise and physical activity for people with dementia and 434, Complementary and alternative therapies and dementia).
Medication may be given to help someone sleep to reduce the risks involved in getting up at night and the resulting strain on carers. If sleeping tablets (hypnotics) are prescribed, it is likely that these will be one of the newer tablets such as zopiclone or zolpidem, which generally don't make people feel unwell. It is also possible that people will be prescribed a sedative antidepressant instead of sleeping tablets, such as trazodone.
If the person and their carer feel that medication would be a good option, the tablets taken should meet their specific needs. For example, some hypnotics last for a short length of time. These tablets are most useful for people who have trouble falling asleep. Longer lasting tablets are more useful for people who find it hard to stay asleep.
Issues to consider when treating sleep disturbance
- If excessive sedation is given at bedtime, the person may be unable to wake to go to the toilet and incontinence may occur - sometimes for the first time.
- If the person does wake up during the night despite sedation, increased confusion and unsteadiness may occur.
- Hypnotics should only be used on a short term basis (less than two weeks), and so are best used intermittently, for example, when the carer and person with dementia feel that a good night's sleep is necessary for either or both of them.
- The use of hypnotics should be monitored by the doctor.
- It is important to have realistic expectations about what duration of sleep should be expected. Older people rarely sleep for more than five to six hours at night, and in people with dementia this will often be spread out over a full 24 hours.
Alzheimer's Society has published a booklet, Reducing the use of antipsychotic drugs: A guide to the treatment and care of behavioural and psychological symptoms of dementia (code 864). Download from alzheimers.org.uk/antipsychotics or order a copy from Xcalibre on 01628 529240.
Last reviewed: January 2012
Next review due: January 2014
Reviewed by: Professor Clive Holmes, Professor in Biological Psychiatry, Moorgreen Hospital, Southampton and Dr Rupert McShane, Department of Psychiatry, University of Oxford and Coordinating Editor, Cochrane Dementia and Cognitive Improvement Group
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