One of the greatest challenges, when it comes to Alzheimer’s disease and other dementias, is coping with sundowning and with difficult behaviors.
These are symptoms beyond the chronic memory/thinking problems that are the hallmark of dementia. They include problems like:
- Delusions, false accusations, paranoid behaviors, or irrational beliefs
- Agitation (getting “amped up” or “revved up”) and/or aggressive behavior
- Restless pacing or wandering
- Disinhibited behaviors, which means saying or doing socially inappropriate things
- Sleep disturbances
These are technically called “neuropsychiatric” symptoms, but regular people might refer to them as “acting crazy” symptoms. Or even “crazy-making” symptoms, as they do tend to drive family caregivers a bit nuts.
And when these behaviors happen in the late afternoon or early evening, it’s usually called “sundowning“. (In most cases, sundowning is triggered by fatigue; anticholinergic medications may cause sundowning symptoms as well.)
Because these behaviors are difficult and stressful for caregivers — and often for the person with dementia — people often ask if any medications can help.
The short answer is “Maybe.”
A better answer is “Maybe, but there will be side-effects and other significant risks to consider, and we need to first attempt non-drug ways to manage these behaviors.”
In fact, until fairly recently, no medication was FDA-approved for the treatment of these types of behaviors in Alzheimer’s disease or other forms of dementia. (For more on the drugs that are FDA-approved to treat the cognitive symptoms of dementia, see here: 4 Medications to Treat Alzheimer’s & Other Dementias: How They Work & FAQs.)
But it has been VERY common for medications — especially antipsychotics — to be prescribed “off-label” for this purpose.
This is sometimes described as a “chemical restraint” (as opposed to tying people to a chair, which is a “physical restraint”). In many cases, antipsychotics and other tranquilizing medications can certainly calm the behaviors. But they can have significant side-effects and risks, which are often not explained to families.
Worst of all, they are often prescribed prematurely, or in excessive doses, without caregivers and doctors first putting in some time to figure out what is triggering the behavior, and what non-drug approaches might help.
For this reason, in 2013 the American Geriatrics Society made the following recommendation as part of its Choosing Wisely campaign: “Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.”
You may now be wondering what should be the first choice. This depends on the situation, but generally, the first choice to treat difficult behaviors or sundowning is NOT medication. (A possible exception: geriatricians do often consider medication to treat pain or constipation, as these are common triggers for difficult behavior.)
Instead, medications should be used after non-drug management approaches have been tried, or at least in combination with non-drug approaches. (Learn about these here: 7 Steps to Managing Difficult Dementia Behaviors Safely & Without Medications.)
Of course, in certain situations, medication should be considered. If your family member has Alzheimer’s or another dementia, I want you to be equipped to work with the doctors on sensible, judicious use of medication to manage difficult behaviors.
In this post, I’ll review the most common types of medications used to treat sundowning and difficult behaviors in dementia. I’ll also explain the approach that I take with these medications.
5 Types of Medication For Sundowning or Difficult Behaviors in Dementia
Most medications used to treat difficult behaviors fall into one of the following categories:
1. Antipsychotics
These are medications originally developed to treat schizophrenia and other illnesses featuring psychosis symptoms. (For more on psychosis, which is common in late-life, see 6 Causes of Paranoia in Aging & What to Do.)
Commonly used drugs: Antipsychotics often used in older adults include:
- Risperidone (brand name Risperdal)
- Quetiapine (brand name Seroquel)
- Olanzapine (brand name Zyprexa)
- Haloperidol (brand name Haldol)
- For a longer list of antipsychotics drugs, see this NIH page.
Newer antipsychotics include:
- Brexpiprazole (brand name Rexulti)
- This antipsychotic was initially FDA approved for the treatment of schizophrenia and as an adjunct for major depression.
- In May 2023, FDA approval was expanded to include the treatment of agitation associated with dementia due to Alzheimer’s disease.
- Pimavanserin (brand name Nuplazid).
- It was FDA-approved in 2016 for psychosis associated with Parkinson’s disease.
Usual effects: Most antipsychotics are sedating, and will calm agitation or aggression through these sedating effects. Antipsychotics may also reduce true psychosis symptoms, such as delusions, hallucinations, or paranoid beliefs, but it’s rare for them to completely correct these in people with dementia.
Risks of use: The risks of antipsychotics are related to how high the dose is, and include:
- Decreased cognitive function, and possible acceleration of cognitive decline
- Increased risk of falls
- Increased risk of stroke and of death; this has been estimated as an increased absolute risk of 1-4%
- A risk of side-effects known as “extrapyramidal symptoms,” which include stiffness and tremor similar to Parkinson’s disease, as well as a variety of other muscle coordination problems
- People with Lewy-body dementia or a history of Parkinsonism may be especially sensitive to antipsychotic side-effects; in such people, quetiapine (brand name Seroquel) is considered the safest choice
Evidence of clinical efficacy: Clinical trials often find a small improvement in symptoms. However, this is offset by frequent side-effects. Studies have also repeatedly found that using antipsychotics in older people with dementia is associated with a higher risk of stroke and of death.
2. Benzodiazepines
This is a “sedative/tranquilizer” category of medication that relaxes people fairly quickly. So these drugs are used for anxiety, for panic attacks, for sedation, and to treat insomnia. They can easily become habit-forming.
Commonly used drugs: In older adults, these include:
- Lorazepam (brand name Ativan)
- Temazepam (brand name Restoril)
- Diazepam (brand name Valium)
- Alprazolam (brand name Xanax)
- Clonazepam (brand name Klonopin)
Usual effects: In the brain, benzodiazepines act similarly to alcohol, and they usually cause relaxation and sedation. Benzodiazepines vary in how long they last in the body: alprazolam is considered short-acting whereas diazepam is very long-acting.
Risks of use: A major risk of these medications is that in people of all ages, they can easily cause both physical and psychological dependence. Additional risks that get worse in older adults include:
- Increased risk of falls
- Paradoxical agitation (some older adults become disinhibited or otherwise become more restless when given these drugs)
- Increased confusion
- Causing or worsening delirium
- Possible acceleration of cognitive decline
In older adults who take benzodiazepines regularly, there is also a risk of worsening dementia symptoms when the drug is reduced or tapered entirely off. This is because people can experience increased anxiety plus discomfort due to physical withdrawal, and this often worsens their thinking and behavior.
Stopping benzodiazepines suddenly can provoke life-threatening withdrawal symptoms, so medical supervision is mandatory when reducing this type of medication. (See How You Can Help Someone Stop Ativan for more information.)
Evidence of clinical efficacy: A recent review of clinical research concluded there is “limited evidence for clinical efficacy.” Although these drugs do have a noticeable effect when they are used, it’s not clear that they overall improve agitation and difficult behaviors in most people. It is also not clear that they work better than antipsychotics, for longer-term management of behavior problems.
3. Mood-stabilizers
These include medications otherwise used for seizures. They generally reduce the “excitability” of brain cells and other neurons.
Commonly used drugs: Valproic acid (brand name Depakote) is the most commonly used medication of this type, in older adults with dementia. It is available in short- and long-acting formulations.
Usual effects: The effect varies depending on the dose and the individual. It can be sedating.
Risks of use: Valproic acid requires periodic monitoring of blood levels. Even when the blood level is considered within an acceptable range, side-effects in older adults are common and include:
- Confusion or worsened thinking
- Dizziness
- Difficulty walking or balancing
- Tremor and development of other Parkinsonism symptoms
- Gastrointestinal symptoms including nausea, vomiting, and/or diarrhea
Evidence of clinical efficacy: A review of randomized trials of valproate for agitation in dementia found no evidence of clinical efficacy, and described the rate of adverse effects as “unacceptable.” Despite this, some geriatric psychiatrists and other experts feel that valproate works well to improve behavior in certain people with dementia.
4. Anti-depressants
Many of these have anti-anxiety benefits. However, they take weeks or even months to reach their full effect on depression or anxiety symptoms.
Commonly used drugs: Antidepressants often used in older people with dementia include:
- Selective serotonin reuptake inhibitor (SSRI) antidepressants:
- Citalopram, escitalopram, and sertraline (brand names Celexa, Lexapro, and Zoloft, respectively) are often used
- Paroxetine (brand name Paxil) is another often-used SSRI, but as it is much more anticholinergic than the other SSRIs, geriatricians would avoid this medication in a person with dementia
- Mirtazapine (brand name Remeron) is an antidepressant that can increase appetite and sometimes increases sleepiness when given at bedtime
- Trazodone (brand name Desyrel) is a weak antidepressant that is sedating and is often used at bedtime to help improve sleep
Usual effects: The effects of these medications on sundowning and on agitation is variable. SSRIs may help some individuals, but it usually takes weeks or longer to see an effect. For some people, a sedating antidepressant at bedtime can improve sleep and this may reduce daytime irritability.
Risks of use: The anti-depressants listed above are generally “well-tolerated” by older adults, especially when started at low doses and with slow increases as needed. Risks and side-effects include:
- Nausea and gastrointestinal distress, especially when first starting or increasing doses (SSRIs)
- SSRIs may be activating in some people, which can worsen agitation or insomnia
- Citalopram (in doses higher than 20mg/day) can increase the risk of sudden cardiac arrest due to arrhythmia
- An increased risk of falls, especially with the more sedating antidepressants
Evidence of clinical efficacy: A 2014 randomized trial found that citalopram provided a modest improvement in neuropsychiatric symptoms; however the dose used was 30mg/day, which has since been discouraged by the FDA. Otherwise, clinical studies suggest that antidepressants are not very effective for reducing agitation. (In fact, randomized trials find that antidepressants do not seem to improve depressive symptoms in people with Alzheimer’s disease.)
5. Dementia drugs
These are the drugs FDA-approved to treat the memory and thinking problems associated with Alzheimer’s disease. In some patients, they seem to help with certain neuropsychiatric symptoms, and they might help with sundowning. For more on the names of these drugs and how they work, see 4 Medications to Treat Alzheimer’s & Other Dementias.
Note: I am not including medications to manage dementia-related sleep disturbances in this post. You can learn more about those here: How to Manage Sleep Problems in Dementia.
If you’re wondering which medication is best for sundowning and difficult behaviors in dementia
You may be now wondering just how doctors are supposed to manage medications for difficult dementia behaviors.
Here are the key points that I usually share with families:
- Before resorting to medication: it’s essential to try to identify what is triggering/worsening the behavior, and it’s important to try non-drug approaches, including exercise.
- Be sure to consider treating possible pain or constipation, as these are easily overlooked in people with dementia. Geriatricians often try scheduling acetaminophen 2-3 times daily, since people with dementia may not be able to articulate their pain. We also titrate laxatives to aim for a soft bowel movement every 1-2 days.
- No type of medication has been clinically proven to improve sundowning for most people with dementia. If you try medication for this purpose, you should be prepared to do some trial-and-error, and it’s essential to carefully monitor how well the medication is working and what side-effects may be happening.
- Antipsychotics and benzodiazepines work fairly quickly, but most of the time they are working through sedation and chemical restraint. They tend to cloud thinking further. It is important to use the lowest possible dose of these medications.
- Benzodiazepines probably increase fall risk more than antipsychotics do, and are habit-forming. They are also less likely to help with hallucinations, delusions, and paranoias. For these reasons, if a faster-acting medication is needed, geriatricians usually prefer antipsychotics to benzodiazepines.
- Antidepressants take a while to work but are generally well-tolerated. They may not improve depressive symptoms, but they seem to make some people with dementia less irritable or anxious. Geriatricians often try escitalopram or citalopram in people with dementia.
- It is usually worth trying a dementia drug (such as a cholinesterase inhibitor or memantine) if the person is not already on these medications, as these drugs also tend to be well tolerated.
I admit that although studies find that non-drug methods are effective in improving dementia behaviors and to manage sundowning, it’s often challenging to implement them.
For people with dementia living at home, family caregivers or paid helpers often have limited time and energy to learn and practice behavior management techniques. Despite the risks of antipsychotics, family members are often anxious to get some relief as soon as possible.
As for residential facilities for people with Alzheimer’s and other dementias, they vary in how well their staff are trained in non-drug approaches.
What you can do about medications and sundowning
If your relative with dementia is not yet taking medications for sundowning and other difficult behaviors, consider these tips:
- Start keeping a journal and learn to identify triggers of difficult behaviors. You will need to observe the person carefully. Your journaling will come in handy later if you start medications, as this will help you monitor for benefits and side-effects.
- If the difficult behaviors really emerge or escalate in the late afternoon or evening, as is typical for sundowning, see if you can avoid fatigue or overstimulation by creating a routine that allows the person to rest quietly by mid-afternoon. You can find more tips to manage sundowning here.
- Learn to redirect and de-escalate difficult dementia behaviors. Contact your local Alzheimer’s Association chapter or local Area Agency on Aging to find support near you. You can also learn a good approach in this article: 7 Steps to Managing Difficult Dementia Behaviors (Safely & Without Medications)
- Ask your doctor to help assess for pain and/or constipation. Consider a trial of scheduled acetaminophen, and see if this helps. (For more on acetaminophen, see How to Choose the Safest Over-the-Counter Painkiller for Older Adults.)
- Consider the possibility of depression. It’s reasonable to consider a trial of escitalopram or a related antidepressant. That said, clinical research suggests antidepressants don’t work well in people with dementia. Research does suggest that in dementia, depression treatments involving certain types of therapy plus positive lifestyle changes is probably more effective than medication.
- If the person is often very agitated, aggressive, or paranoid, or if otherwise the behavioral symptoms are causing significant distress to the older person or to caregivers, it’s often reasonable to try an antipsychotic.
- Be sure to discuss the increased risk of stroke and death with the doctor and among family members. This can be a reasonable risk to accept, but it’s essential to be informed before proceeding.
- It’s best to start with the lowest dose possible.
- If there have been visual hallucinations or other signs of possible Lewy-Body dementia, quetiapine (brand name Seroquel) is usually the safest first choice to manage sundowning or other difficult behaviors.
- For all medications for dementia behaviors:
- Monitor carefully for evidence of improvement and for signs of side-effects.
- Doses should be increased a little bit at a time.
- Especially for antipsychotics, the goal is to find the minimum necessary dose to keep behavior manageable.
If your relative with dementia is currently taking medications for behaviors or for sundowning, then you will have to consider at least the following two issues.
One is whether the behavior issues currently seem manageable or not. If the behaviors are still often very difficult, then it’s important to look into triggers and other behavioral management approaches.
Ongoing agitation or difficult behaviors may also be a sign that the medication isn’t effective for your relative. So it may also be reasonable to consider a change in medication. The best is to work closely with a doctor AND a dementia behavior expert; some social workers and geriatric care managers are very good with dementia behaviors.
The other issue is to make sure you are aware of any risks or side-effects that the current medications may be causing.
The main side-effects I see people with dementia experience are excess drowsiness, excess confusion, and falls. These are usually due to high doses of antipsychotics and/or benzodiazepines. In such cases, it’s often possible to at least reduce the dosages somewhat. Addressing any other anticholinergic or brain-dampening medications can also help.
Now should you aim to get your relative completely off antipsychotics, in order to reduce mortality risk, improve alertness and thinking, and to reduce fall risk?
I have found that sometimes tapering people completely off antipsychotics is possible, but it can be a labor-intensive process. Furthermore, studies find that a certain number of people with dementia “relapse” after antipsychotics have been discontinued. Another very interesting 2016 study of antipsychotic review in nursing homes found that stopping antipsychotics tended to make behavior worse unless the nursing home also implemented “social interventions.”
In other words, attempting to completely stop antipsychotic medications involves effort, may be followed by worse behavior, and is less likely to succeed if you cannot concurrently provide an increase in beneficial social contact or exercise. It is certainly worth considering, but in people who are taking more than the starter dose of antipsychotic, it can be challenging.
No easy solutions but improvement IS usually possible
As many of you know, behavior problems are difficult in dementia in large part because there is usually no easy way to fix them.
Many — probably too many — older adults with Alzheimer’s and other dementias are being medicated for their sundowning or other behavior problems.
If your family is struggling with behavior problems, I know that reading this article will not quickly solve them.
But I hope this information will enable you to make more informed decisions. This way you’ll help ensure that any medications are used thoughtfully, in the lowest doses necessary, and in combination with non-drug dementia behavior management approaches.
To learn about non-drug management approaches, I recommend this article: 7 Steps to Managing Difficult Dementia Behaviors (Safely & Without Medications).
And if you are looking for a memory care facility, try to find out how many of their residents are being medicated for behavior or for sundowning. For people with Alzheimer’s and other dementias, it’s best to be cared for by people who don’t turn first to chemical restraints such as antipsychotics and benzodiazepines.
This article was last updated by Dr. K in February 2025.
Stacy says
Hello. My husband was diagnosed at age 52 with early onset of dementia. He is 55 now and is becoming agitated, negative, over sexual and now the biggest issue is paranoia. He has been taking 5 mg of Aricept twice a day and 5 mg of memantine twice a day. My son and I are overwhelmed with his behavior. What do we do about the paranoia? I don’t know if he is in mindset or what now.
Leslie Kernisan, MD MPH says
For significant paranoia or problematic delusions, we sometimes try a low dose of antipsychotic. As noted in the article, there are a lot of downsides to using these drugs. But if the paranoia and delusions are causing significant distress for the person with dementia or for family, then the benefits may outweigh the risks.
Before starting an antipsychotic, please see my recommendations under the section “If your relative with dementia is not yet taking medications for behaviors.” You want to be sure you’ve tried non-drug approaches before resorting to antipsychotics.
In an earlier comment, a reader mentioned that her husband’s hypersexuality responded well to sertraline (brand name Zoloft), which is an SSRI-type antidepressant. You may want to ask your husband’s doctors about trying an SSRI for this purpose. (It might also help with his mood and other symptoms.)
I am sorry to hear that your husband has developed dementia at such a young age. Usually, people like him are evaluated in memory clinics, and many such clinics have social workers and additional support services available. The medical specialists there may have additional ideas that are likely to work in someone of his age, and with his particular type of dementia. Good luck!
Bob Whiston says
Hello, I’m right there with you! My wife got diagnosed at 50 and at 54 we finally got her into a memory care facility yesterday. They called to have her baker acted this morning due to her anger, hallucinations, and unrestfulness. Once she has been evaluated they are sending her to a psychological inpatient care to get her leveled out. It has been anything but fun finding help due to her age. If it wasn’t for the memory care stepping in our 2 teenage daughters and myself would be left with fighting doctors who won’t change medications that will help or even see her within a reasonable time. This has been heart breaking for all of us.
Nicole Didyk, MD says
Thanks for sharing your experience and I’m glad that there are some helpful resources in your area. Younger onset dementia is different to that of dementia that comes on in older age, as you describe.
I have a YouTube video about this topic that you might find interesting: https://www.youtube.com/watch?v=RzFqyQhHE_U
Stephanie says
My has become very violent with staff and residents. He was transferred from his memory care unit to a behavioral health unit in a hospital. He is on .5 mg Ativan 4x/day, .5mg Haldol 4x/day and 1 tablet (?mg) of Norco as needed for pain in his back. He is still exhibiting aggressive behaviors after 5 days. I am getting mixed messages from nurses and doctors. Some feel it is too soon to determine whether the aggression can be controlled and others think there’s no hope. No other drugs have been tried and doses have not been altered. What should I be expecting? Is it too soon to know where this may lead? Should they be trying other medications?
Leslie Kernisan, MD MPH says
This sounds like a difficult situation for everyone involved.
When aggression comes on fairly quickly (e.g. over hours to days), we normally search for anything that might trigger pain, discomfort, or delirium. So we would check and make sure he didn’t seem to be hurting somewhere, didn’t have constipation, and then we would also check for other delirium triggers such as infection, electrolyte imbalance, dehydration, medication side-effect, etc.
One tablet of Norco per day would not be enough to manage an ongoing pain problem, such as a new painful fracture in one’s vertebrae. (But if he’s on pain meds, you also want to make sure he’s not getting constipated from them.)
A violent person often does require at least temporary chemical restraint, for the safety of everyone else. We don’t usually use benzodiazepines as they can disinhibit older adults and cause paradoxically worse agitation; it is often possible to manage an aggressive episode just with antipsychotics. Chemical restraint scheduled for 4x/day seems like a lot, we would usually schedule at most 1-2 times per day and otherwise use as needed doses, because the goal should be to control the behavior with the minimum amount of medication necessary.
So…you might want to ask them questions about why they feel both the ativan and haldol are necessary. You could tell them you’ve read that Ativan can agitate older people with dementia and ask if they might consider using just an antipsychotic, if chemical restraint remains necessary.
And I would certainly encourage you to make sure they investigate what brought this on. Hopefully the situation is temporary and he will improve soon. Good luck!
Dewayne Reynolds says
My wife was diagnosed with PPA at the age of 50 we believe and have been told that it has progressed to Alzheimer’s. She was agitated the first day and within 8 hrs was sent to a behavior facility and put on all these med’s that your talking about. Please help I beg you
Leslie Kernisan, MD MPH says
By PPA, I’m assuming you mean primary progressive aphasia.
I am sorry to hear of your wife’s decline and even more sorry to hear that the facility started medication for agitation so quickly.
Unfortunately, all I can do is offer a little information and encouragement. If you’re concerned about your wife, you will need to ask a lot of questions and otherwise advocate for her. Those medications must have been prescribed by a clinician. You can ask to speak to the clinician, and express your desire for your wife to be on the minimum medication possible, or medicated only as a last resort. You can also complain about the medication to the facility, and ask the nursing director to explain to you what non-drug interventions they tried, or what they are planning to do in order to avoid medicating your wife indefinitely.
You may find it helpful to connect with other Alzheimer’s caregivers through a support group, either online or in person. Many people are in your situation, and will have encouragement and practical advice to share.
Good luck!
Troy says
My dad, who has advanced dementia, was put on 750mg of depakote to deal with his sexually inappropriate behavior. Several months later, he developed almost all the side-effects you describe–vomiting, some hand tremors, difficulties walking, even more confused thinking. Of course the powers that be are saying this is the dementia worsening–and it could be–but I am livid that no one ever discussed such side effects with me. At my insistence, they’re lowered the dose to 375mg a day–but not much change so far, after 3 weeks. Think there could be?
Leslie Kernisan, MD MPH says
Parkinsons-like symptoms (which include tremors and stiffness, and sometimes difficulty walking) are known to develop in some people who take depakote. Often these symptoms resolve when the drug is discontinued, but apparently it can take weeks, and occasionally, the problems persist.
It’s too bad if you weren’t notified of potential side-effects but also not that surprising…most drugs have a long list of “not so likely but not vanishingly rare” side-effects, and doctors often feel it’s not feasible to discuss all these possibilities with patients and families. In truth, I think it’s a bigger problem that usually families aren’t informed that there isn’t much research supporting the use of many of these medications.
You should certainly discuss your depakote concerns with your father’s doctors. It may be reasonable to further taper down his depakote and see how he is, both in terms of inappropriate behavior and in terms of the other symptoms you are concerned about. Good luck, I hope you find a better solution for your father.
Afton Jackson says
My grandmother has been suffering from dementia for a little while. We want to make sure she is healthy and happy, so we’re looking at different treatment options. I never realized keeping a journal can help family members understand what triggers different behaviors. I’ll be sure to discuss this info with my family.
Leslie Kernisan, MD MPH says
Yes, figuring out what triggers a person can be really valuable, and a journal makes it easier to do this. Good luck!
Jenny says
My mother had been prescribed Valproic acid for late middle stage Alzheimers. Lately, she has has become aggressive and very agitated without provocation. Just seeing herself in the mirror elicits an argument with herself, not to mention family members.
The clinic refuses to give my dad even small occasional doses of benzodiazepenes, citing the debunked study of causing the disease to speed up. What bothers me is that they are not even testing her blood as needed for the current drug, and they are willing to give her haldol – even though she is experiencing difficulty using her hands now! It’s ok to have difficulty in movement (falls?) or tardive dyskensia of course. Is the fact that it is a controlled drug playing a small part in this? My poor dad can’t leave the house with her, and I feel as if they should be transparent in why their hands are tied. She’s not going to get better and my dad needs to live out his life at least in peace. He does’t want to institutionalize her, but the medical community is worthless.
Leslie Kernisan, MD MPH says
This sounds like a difficult situation. It’s unfortunate if you feel the involved clinicians aren’t communicating with you well enough.
I have to say that most of us in geriatrics are very reluctant to prescribe benzodiazepines for people with dementia and difficult behaviors. After trying non-drug methods to address agitation, I do usually try a low-dose antipsychotic. Movement difficulties due to antipsychotics can happen, but that’s usually at higher doses. Of course, I cannot say is this would be a reasonable approach for your mother, especially given you report some difficulty with her using her hands.
It is also true that benzodiazepines may be perceived as having more “street value” and so some clinicians worry about them being used or diverted by someone else in the household. They are also more complicated to prescribe since they are a controlled substance.
I would encourage you to keep trying to discuss your concerns with the clinicians. Emphasize that your father really needs help. Consider a trial of what your mother’s doctors recommend, and see how she does. If it doesn’t provide enough help, work with the clinicians on trying something else. If the communication continues to be unsatisfactory, then your family might want to consider getting a second opinion. Good luck!
Mary Church says
Aloha and thank you for this article. I cared for my Mom with Alzheimer’s for many years in the home. The disease led to a disinhibited hyper-sexual response that was very difficult to manage, but very well treated by Zoloft. I thought it was ironic that the same “negative side effect” of this drug (sexual disarousal) resulted in a very effective “off-label” application. Can you disseminate this? Thank you!
Leslie Kernisan, MD MPH says
Oh, that is indeed very interesting, thank you for sharing this story. Alzheimer’s does often cause disinhibition and some people do become sexually in appropriate. I’m not sure it had ever occurred to me to try an SSRI for that specific purpose, but you are right, it makes sense given that decreased libido is a common side-effect. I will have to ask my geriatric psychiatry colleagues about this next time I see them. Thank you!
Kim says
My mother’s GP put her on citalopram and I don’t see it working for her-in fact I think it has made her worse. When I expressed that to the doctor, he pretty much dismissed me and said that wasn’t the problem. We aren’t going back to him.
Leslie Kernisan, MD MPH says
Citalopram is well-tolerated by most older adults but it doesn’t work for everyone. It’s also possible for it to make some people worse.
That is really too bad that your doctor didn’t take your concerns seriously. I hope you can find someone who will be a better partner to your family.
Rebecca says
My mother is on citalopram and it seems to help her sleep and with sundowning behaviors, but I do notice that about 45 minutes after the she gets a mean streak which lasts about an hour or so. We know that it is the drug because we have tried changing the timing of the medication, with the same results.
We are still looking for a better alternative, but no luck.
Nicole Didyk, MD says
“Sundowning” is the increase in responsive behaviours around dusk in people living with dementia. There are some practical things to do to lessen sundowning, but medicaitons are often used as well.
I’ve had patients describe similar types of reactions with various medications but honestly, it’s very difficult to make sense of how this could happen. Citalopram reaches a peak level in the blood at around 1 – 6 hours after the dose is given, but I’m not sure why that would cause a one hour episode of meanness. Perhapos dividing the dose into 2 parts, half in the morning and half later would give a more consistent level and less chance of the experience you describe.
Best of luck!
Rebecca says
We had the exact same experience with citalopram in my mother, 95, with dementia. It helped greatly with her sundowning, but we noticed that 45-60 minutes after her dose, she experienced a mean streak which lasted for an hour or two. She was never a mean person, and this side effect occurred no matter what time we gave the dose. By trial and error, we came upon a dose of only 5mg daily. Her geriatrician was clueless that this could be a side effect of the drug.
It seems that no one (in the medical realm) really knows what works for dementia, or how these drugs help or not help. I only wish that the allopathic doctors would get together with the naturopaths or other alternative providers to try to figure this out.
Nicole Didyk, MD says
Good job being patient and sorting out the right dose of citalopram for your mom. It would be unusual for citalopram, an SSRI antidepressant to cause temporary meanness, but any medication can cause any side effect it seems!
I too wish we had better, more holistic treatment options available for people living with dementia. Thanks for sharing your experience.
Sheryl says
Definitely gave my mom extreme nausea and scared to death. Didn’t want me to leave her. I think there is a certain percentage that cannot take it. She was on the lowest dose.
Bally Singh says
Very helpful for Senior Care providers and Caregivers!
Angela G. Gentile says
Excellent article, Dr. Kernisan. Thank you for sharing your wisdom on medications used to treat behavioural challenges in dementia. I like how you emphasize medications should not be the first line of defense. I see medications being prescribed too quickly, especially in nursing homes. They have their place, but only as a last resort. Assessing for delirium and depression are also important factors. Thanks again.
Leslie Kernisan, MD MPH says
Glad you found this useful. Yes, nursing homes can be challenging because the staff are often overworked. Providing non-drug dementia care requires investment in training staff and supporting them.
Jim Dickerson PharmD says
Very interesting article with also finite suggestions; I am currently writing a book for Consulfant Pharmacists in LTCFs on the top 10 disease states with Alz Dis. as the first chapter. Thank you for a few suggestions especially on Paxil. Never thought much of that drug except in PTSD. So Brava to you for your insights. Jim Dickerson Rp,PharmD, Gretna,Ne
Leslie Kernisan, MD MPH says
Glad you found this helpful. Yes, in the US, Paxil is unpopular with geriatricians, we feel that citalopram and sertraline have more favorable side-effect profiles in vulnerable older adults.
Of course as you know, the ideal is to treat problems without medication whenever possible, but such non-drug methods often require time, effort, and some training of family and long-term care providers.
Good luck with your book!
Margaret says
My father was on the majority of these medications. My mother had called 911 three times because of his anger and violence. We were fortunate that a psychologist, dealing in geriatric patients only, saw him the jjthird time. He was a godsend. It took about a year to find the right medications and strength to stabilize him. We had no idea he had dementia. About a year prior he had a severe backwards fall on the stairs leading to the front door. He landed head first against the front door. How he came back from that I don’t know. He was put in a coma for 2 weeks afterwards. We assumed his violent behaviour was due to brain damage from the fall. Also, my dad had always been an angry, agitated and violent person. His anxiety and depression had gone untreated for years. Prior to his dementia he had calmed down quite a bit. His anger from dementia was 24/7, it never went away and you had to be on guard all the time. Anyways, yes, the drugs had a dramatic effect on his personality. He became someone I no longer recognized. And over the 10 years he suffered with dementia my mother worked with his doctor, increasing and decreasing the mg on these medications when she felt something was wrong. I can’t imagine how long he would have lived without these meds.
Leslie Kernisan, MD MPH says
Thanks for sharing your story. I’m so glad your family was able to find a health provider with the right expertise to work closely with you and help you. It does often take some trial and error and also adjusting as the person’s brain changes over time.
Depro67 says
So glad to see an open dialog discussing the pros and cons INCLUDING MED management ESPECIALLY the benzodiazepines. They can help or hinder but should NOT BE ERADICATED!! We, some patients, require trials to observe responses and it is pure negligence to prohibit us from testing and forced negative experiences because we are denied access to testing and options by wholistic practitioners who simply refuse to accept that many patients require meds deemed addictive, dangerous or otherwise “bad” based on NO individual science
Leslie Kernisan, MD MPH says
I agree that it’s not a good idea to have a blanket “no risky meds” approach. I feel that great caution should be exercised before starting them — or agreeing to prescribe them for a new patient. But in some cases, the likely benefits seem to outweigh the risks. And for people who’ve been on them for a while, just stopping over a short period of time is usually not viable.
Anjali Roy says
Please help me my father suffering from dementia.
Nicole Didyk, MD says
Hi Anjali,
I’m glad you found this site and that you reached out!
There are lots of articles about dementia on the site, such as this one about diagnosis, this one about sleep problems in dementia , and this one about medications. There are also numerous podcasts.
The Helping Older Parents Membership is also a wonderful opportunity to get practical advice about the best way to help your father and maintain balance in your own life.
Alana Peterson says
My father has been making growling noises and howling wolf noises all night long! We are long suffering as caretakers. Clonapam doesn’t work, donezipil either. He fights us andthreatens to punch us in the face, if we change his diaper. Help!!!
Nicole Didyk, MD says
That sounds like a responsive behaviour in dementia. I made a YouTube video about that, which you can watch here: https://youtu.be/o-pmHQdKzq0
Even though it may seem to make no sense, your father is expressing some unmet need like discomfort, pain, boredom, or something else. Trying to identify what’s triggering the behaviour and modifying his environment, or your approach will probably work better than medication, as you mention.
If there are specialized Geriatrics or dementia services in your area, this would be a good time to ask your family doctor to arrange a referral. Caregiving is incredibly difficult when the care recipient is fighting back. It could escalate into a situation where injury occurs.
Another thing to remember is that behaviours are usually time limited, so this won’t last forever. I hope you can access some local resources and get some rest.
Richard Toft says
Thank you for the article. It helped a lot, I suffer from dementia and was worried about starting benzodiasapans
Nicole Didyk, MD says
I’m glad you found the article helpful, Richard. It’s great that you’re thinking carefully before starting a new medication and considering the risks and benefits for you.
Jennifer landry says
Me and my boyfriend live and take care of his 87 yr old grandmother who has moderate to sever alzheimers. She is very very rude, disrespectful and aggressive to me! She has threatened to hit me with her cane and even had it up in the air and coming at me with it. My bf got in front of her. Honestly. I’m at my end here. Don’t know what to do or how much longer I cam live like this. Any help will be appreciated
Nicole Didyk, MD says
It sounds like your boyfriend’s grandmother is having responsive behaviours of dementia. I made a video about that, which you can watch here: https://youtu.be/o-pmHQdKzq0.
It’s vital to make sure there isn’t a medical issue that’s triggering this change. I would suggest a visit to her doctor to sort this out.
In the end, it may be that there’s something about you that’s the trigger, Don’t take it personally, and realize that dementia can play tricks on a person’s brain. Getting to the root of the behaviour will be the key to figuring out how to avoid her responses.
p. horn says
I have been working with care facility and doctor to reduce list of meds-is off morphine and sertraline with an astonishing change in alertness and understanding. however, there is now an increase in belligerent behavior, and suspicion. not sure if this will change, or it will be necessary to medicate again. hard to tell if he is just being himself, or if he has a real problem!!!!!
Leslie Kernisan, MD MPH says
Well, it sounds like reducing those medications has improved the overall activity in his brain, so he is more alert. Usually an opiate like morphine is more sedating than a medication like sertraline, which isn’t very sedating for most people.
Suspiciousness is quite common in dementia, especially if a person is feeling anxious or if the environment doesn’t feel reassuring and familiar.
Belligerence is also common. It’s important to check and see if some kind of uncomfortable symptom might be causing it. Presumably the morphine was to treat pain. Does he still need some kind of treatment for pain? I find that some of my dementia patients are more agreeable once we start a very small dose of opiate, or some other effective medication for pain. Or are there other things going on that might be putting him ill at ease and triggering irritability?
You basically need to explore the situation a bit, and then also give things a little time. Hopefully things will become clearer as you go through your process of trial-and-error. Good luck!
Yan P says
Very good article.
Mom was a very Profound behavior disruptions Alzherman’s client. Very hyper, insomnia, strip herself in public area non stop… Just wear me off. ..
She was on Depakote, but sooner noted stiffness on her neck and difficulty walking… have to stop.
Dr. just start on Seroquel …
At night if give PRN Temazepam plus ativan she may sleep 4-5 hrs, then restart all bizarre activities again. Sleepy at day.
Do you think Lithium and ECT will be better for her or not ?? Is ahe need go to senior Mental Hospital for eval?
The only good thing for her is she compliance w/ the medication and cooperate w/ behavior correction ( but Just in 10 min, she will repeat again).
Long memory are good , and no short memory
Leslie Kernisan, MD MPH says
Sorry that these behaviors are so difficult.
Lithium is sometimes used to treat bipolar disorder in older adults but it’s not a treatment for difficult behaviors associated with Alzheimer’s or related dementias. Electroconvulsive therapy is a treatment for very serious depression, not for dementia.
Temazepam and lorazepam (brand name Ativan) are both benzodiazepines, we try to avoid using them in geriatrics and we generally don’t give two drugs in the same class.
Generally if you are struggling then it’s a good idea to get an evaluation and then tailored advice on how to manage. She may improve with certain behavioral techniques. good luck!
Catherine says
I have early onset dementia and there are so many medications that they give patients with dementia that make them so much worse and antipsychotics most of the time do I don’t think they should ever be considered. A low-dose of the bench that would be a better and safer route. Anti-depressants as well have done nothing but made me worse over the years and changed who I was as a person I am perpetually hyper. I have seen many other people put on antidepressants and other medications to find out that the recourse was neurological, but even when they know that they’re still trying to push this drugs on us because they don’t know. Then I’ve witnessed many people not being treated for pain because they didn’t believe they were actually in pain. One nurse said he’s not in pain he’s just screaming because he has dementia, but it was obvious by the sounds of the scream they were that of pain. I also believe she said they don’t feel pain and some people actually believe we don’t feel pain the way others to. I’m sure there’s some type of demyelination going on. I’m sorry I’m just angry, because every time I go to a doctor and they try to give me a medication I have to tell them I can’t take that and that is not my job to know which medicines I can take. Someone with the LBD given an antipsychotic is very dangerous. With most patients they don’t even know definitively if they have other dimensions. I think it’s dangerous without having a definitive answer. It says you’re playing Russian roulette with their lives
Nicole Didyk, MD says
Hi Catherine and thanks for sharing your thoughts. I’m sorry to hear about the negative experiences you’ve had with medications and the health care system. There is a lot of misconception and misinformation about dementia, even among health professionals, as you mention.
I think you make a great point about pain as a potential cause for behaviour changes, and this is often unrecognized. There’s no evidence that people with dementia are less sensitive to pain, and diagnosing and treating pain in those with dementia can be complex, but is so important.
As a Geriatrician, I do prescribe medication in those with dementia, but we always work in an interprofessional team to find non-medication treatments to use as well. Here’s a video I made about that which you can watch here: https://youtu.be/o-pmHQdKzq0
Sheila Thompson says
I am devastated, my husband has PPA a rare Vascular Dementia.has been in care home 13 months. He was on Risperidal for all that time, they said he was getting aggressive so it wasn’t workingvanymore, took him off cold turkey & put him on Nozinan 2 weeks ago, he has been very violent at times on this drug. Today was my visit he didn’t come the said he was violent, tried to break a carers arm & onothers thumb thank god they didn’t break. They phoned me again & said he thru a cup of hot tea in carers face she ducked. I asked fir him to be taken off this drug right away as it was a mind altering drug & changed him. They phoned again to say if there was another incidence today they would phone the RCMP & take him to Pych Ward an hour away. God I am at rock bottom don’t know what to do. They just phoned again & syc Dic doc said NO we will increase it. What can I do,
Nicole Didyk, MD says
I can’t imagine how stressful this must be for you and your family. By PPA, I assume you’re referring to Primary Progressive Aphasia, which is a type of dementia that is usually grouped in with the frontotemporal dementia types. It usually affects language, and can cause changes in behaviour, as with most types of dementia, especially in later stages.
It’s very hard to determine if the behaviour of a person with dementia is caused by the effects of a medication, or by the dementia itself, or if there’s some other trigger that hasn’t been identified (like pain, hunger, fear. or other discomfort). Sometimes it’s a combination of all of the above. The best approach is to try to figure out if there are any unmet needs and get the care team to offer a consistent, gentle approach. Unfortunately, when the person’s responses are such that they could create safety issues, we often turn to tranquilizers like risperidone and nozinan, to try to sedate the person first, and figure out a longer term approach later.
In such a case, I would find out if the care home has access to a Geriatrician or Geriatric Psychiatrist, even over the phone or by videoconference, to offer advice about what to do to avoid a trip to hospital.