Alzheimer's and Psychoactive Medications -- A Controversial Decision for Caregivers

02/17/2012 04:12 pm ET | Updated Apr 18, 2012

Lisa walks into the nursing home room of her elderly mother, who has Alzheimer's. She's sitting in a chair blankly staring at the floor. Her head is hanging down. She doesn't smile or even look up when Lisa greets her. It's been like this for months. Symptoms of Alzheimer's? Nothing can be done about it? Maybe. Maybe not. Perhaps Lisa's mother is clinically depressed and an antidepressant could make a difference.

Alzheimer's disease is often accompanied by serious behavioral and emotional problems such as depression, restlessness, irritability, anxiety, anger and aggression, just to name a few. The first step in dealing with these is to get a thorough medical evaluation to be sure that other health issues are not causing or contributing to the problem.

The next course of action should be trying non-pharmacological approaches to the problem. These include things such as physical exercise, mentally and socially stimulating activities, pet therapy, music therapy, changes in the environment and other approaches. The Alzheimer's Association lists several such methods on its website.

But if those approaches don't work, your loved one is suffering severely, and you're at your wits' end, you may want to consult a neurologist, geriatric psychiatrist or geriatrician about trying a psychotropic medication. Some studies have found, for example, that up to 50-75 percent of depressed people with dementia improve when put on an antidepressant.

The physician may recommend an antipsychotic if the person is exhibiting any of the following:

  1. The symptoms (such as delusions, hallucinations, sleeplessness, paranoia, extreme aggressiveness or violent behavior) are being caused by mania or psychosis
  2. The symptoms present a danger to the patient or others
  3. The patient is suffering from inconsolable or persistent distress
  4. The patient has had a significant decline in function
  5. The symptoms are preventing the patient from receiving needed care

A study published in Lancet states that antipsychotics have little beneficial effect for any Alzheimer's patients. Other research, however, has found that approximately two-thirds of patients with agitated behavior improve with antipsychotic treatment, although the response is generally modest and some patients do not benefit.

Despite their potential effectiveness, though, these drugs can have very serious side effects, and the elderly are especially sensitive to them. Further, antipsychotics (both the older and newer ones) are associated with an increased risk of mortality in older adults with dementia.

In fact, the FDA has clearly stated that antipsychotics are not specifically indicated for the treatment of dementia-related psychosis. In addition, a 2006 article in the New England Journal of Medicine concluded that the risks posed by these drugs outweigh the benefits in Alzheimer's patients. But the Alzheimer's Association has a slightly different view. It states:

If non-drug approaches fail after being applied consistently, introducing medications may be appropriate for individuals with severe symptoms or who have the potential to harm themselves or others. While prescription medications can be effective in some situations, they must be used carefully and are most effective when combined with non-drug approaches.

The Alzheimer's Association also states: "Some behaviors may be so frequent and escalating that they result in harm to the person with dementia and caregiver that will in essence limit the life-expectancy and/or quality of life of the person with Alzheimer's Disease."

According to Robert Cluxton, Pharm.D., professor of Pharmacy and Family Medicine at the University of Cincinnati, "Unfortunately, there often is no other reasonable choice than to use an antipyschotic. If the patient's behavior results in a danger to themselves or those around them, then the benefit justifies the risk."

Many people refuse to even consider having their loved on put on any psychotropic medication for any reason. And that's understandable. These drugs have a bad reputation because in the past nursing homes often used them to drug "problem patients" into submission. They were, and in some cases still are, given in high doses that turned them into zombies.

But today's medications, which can be given in doses that don't overly sedate patients, can be effective and improve a patient's overall quality of life, which also improves the quality of life for the caregiver. Cluxton states that "Using the lowest possible dose for the shortest period of time will decrease the likelihood of an adverse event." This is the key advice that can prevent the horrors that are experienced by some Alzheimer's patients taking antipsychotics.

I had the personal experience of seeing my mate, Dr. Edward Theodoru, transformed when put on both an antidepressant and an antipsychotic. He changed from being depressed, agitated and having hallucinations and delusions to being one of the most contented, calm and lovable people you'd ever want to meet. And the medications did not sedate him. This amazing transformation is detailed in my book, Come Back Early Today: A Memoir of Love, Alzheimer's and Joy.

If you're faced with the decision to medicate or not medicate, you must weigh the pros and cons -- especially regarding antipsychotic drugs. For patients with the most severe symptoms -- and only those with the most severe symptoms -- it basically comes down to this: Would you rather have your loved one continue living with agitation, psychosis, mania or other extreme conditions, or would you rather try to afford your loved one a better quality of life despite the risks?

A daunting decision for caregivers.

For additional information on this topic talk to your loved one's physician, get a consult from a physician specialized in care of the elderly, and go to the Alzheimer's Association website to read more about pharmacological and non-pharmacological treatments for severe behavioral symptoms in people with Alzheimer's.

Disclaimer: The information in this article should not be construed as medical advice. One should always consult a qualified physician when making decisions about any medical issue.

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