Definitions: We don't really need to tell you what the challenging behaviors in dementia can be, you live this life every day. But to make sure we are on the same page, in this article we are talking about behaviors such as:

• Agitation
• Aggression (physical or verbal)
• Depression or anxiety
• Irritability/emotional lability
• Paranoia, delusions, or hallucinations
• Apathy
• Insomnia
• Repetition
• Wandering
• Sundowning
• and others…

Before we get into it…: Medications are often thought of as the first, or as the most effective way of managing challenging behaviors in dementia, when in reality neither is true. Frequently, the best approach to managing behavioral symptoms in dementia is usually non-drug strategies. These include:

Maintaining a consistent daily routine

Creating a calm, safe environment

Offering meaningful activities

Using structured approaches like the DICE method: Describe, Investigate, Create, Evaluate – which helps caregivers understand and address behaviors. DICE Approach

Non-drug strategies should always be tried first as long as there is no imminent safety concern, and should still be tried alongside medications if they are prescribed. Non-drug strategies have often been show to be as or more effective than drug strategies in comparison studies–it is not only a testament to how much power and impact that caregivers can have, but also a statement that the medications themselves do have their limitations, and should not be considered “cure-alls” if prescribed. 

SSRIs (Selective Serotonin Reuptake Inhibitors)

Selective serotonin reuptake inhibitors are, in most cases, our preferred and first-line agent for managing behaviors in dementia. SSRIs are a class of antidepressant that works by increasing the amount of available serotonin in the brain, thereby improving mood and anxiety symptoms. They have also been shown in smaller studies to impact other behavioral symptoms as well, such as agitation, irritability, and apathy. They are preferred for their relative safety profile compared to the other medication options. 

Common examples:

Citalopram (Celexa)

Sertraline (Zoloft)

Escitalopram (Lexapro)

Onset of action:

2-6 weeks

Medication duration:

SSRIs can be taken indefinitely if desired, as long as there are no issues.

Side effects to watch for:

Gastrointestinal upset (nausea, diarrhea)

Sleep changes (drowsiness or insomnia)

Headache or dizziness

Changes in heart rhythm or fainting (rare, usually with higher doses of citalopram). Sometimes we may request an EKG with citalopram to monitor for this.

Possible interactions with other medications (such as blood thinners)

Caregiver tips:

Monitor for worsening agitation or new behaviors.

Never stop abruptly; medication needs to be tapered with guidance from your physician/care team.

Follow up with care team 4 weeks after starting.

Antipsychotics

Antipsychotics have been used for severe behavioral symptoms in dementia for over fifty years, and have long been an exercise in risk versus benefit. While newer antipsychotics are somewhat less harmful than their predecessors, they nonetheless can still carry very significant side effects such as stroke, movement disorders (which can be permanent), falls, and higher all-cause risk of death. These medications will generally have a FDA black box warning for use in dementia for this reason. That said, sometimes behaviors in dementia can be so severe that they become outright dangerous toward the person living with dementia themselves, and/or their caregivers, so there are still times and situations where antipsychotics are the best (and perhaps only) solution to a difficult problem.

Common examples:

Risperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Aripiprazole (Abilify)

Brexpiprazole (Rexulti)

Side effects to watch for:

Sedation or drowsiness, increasing risk of falls

Movement problems (tremor, stiffness, or slowed movements). Bizarre or repetitive movements, especially of face and mouth.

Dizziness or low blood pressure when standing

Changes in heart rhythm, or fainting (same as with SSRIs)

Weight gain or metabolic changes (especially olanzapine)

Signs of stroke, go immediately to emergency if so

Increased risk of infections, such as pneumonia or urinary tract infection

Onset of action:

In the literature it is described as 2-4 weeks, however sometimes we have seen these medications having an impact in as quickly as a few days.

Medication duration:

12 weeks at most. They should be taken for as short of a time as possible. Often we will try to bridge to an SSRI once the most dangerous behaviors are stabilized.

Caregiver tips:

These medications have a litany of possible side effects beyond what is listed. If there is a new medical issue around the time of medication start, it is often because of these medications. Please let your care team know.

Do not stop these abruptly. They should be tapered, similar to SSRI.

Follow up with care team 2 weeks after starting, then once a month afterward.

Other Medications

SSRIs and antipsychotics are the two major classes of medications prescribed to help with challenging behaviors in dementia. Other medications can sometimes be used; most often these are for targeting specific behaviors, in a specific set of circumstances, or if none of the SSRIs or antipsychotics work or can be tolerated. 

Examples:

Trazodone – usually primarily as a sleep aid, with mild antidepressant properties and some limited evidence for behavioral symptoms such as nighttime agitation

Melatonin – usually primarily as a sleep aid, available over the counter without a prescription, some limited evidence for helping in sundowning.

Mirtazapine – usually considered when need for both mood improvement and weight gain, but some limited evidence that it can help with behavior as well

Anti-seizure drugs (e.g., valproate, carbamazepine) – very limited evidence for use in challenging behaviors in dementia. Prescribed by neurologists, also high side effect profile

Other dementia medications (e.g. donepezil, rivastigmine) – used commonly for general cognition in dementia, these have some very limited evidence to also help behavior