5 Types of Medication Used to Treat Sundowning & Difficult Dementia Behaviors

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.”

[Read more…]

4 Things to Try When Your Aging Parent Seems Irrational

by Leslie Kernisan, MD MPH

Dear Dr. K,

Any ideas on how I can relieve my mother’s anxiety about her thinking an animal got in the house? I can’t find anything and have moved the couches but she is convinced and scared.

She’s always been a worrier, plus her thinking has been deteriorating and her vision is impaired a bit. I take care of her and my Dad both 94. She gets upset if I tell her I think she just thought she was seeing something and says I think she is crazy. Last night she woke me up shaking and practically in tears because she thought she saw it again -I offered for her to come sleep with me but she wouldn’t. Any suggestions? — C.S.

Thanks so much for sending in this question. This is a very common complaint I hear from family caregivers, so I am happy to share some thoughts about what might be going on and what you can do.

Now, I can’t say for sure what is going on with your mother. That’s because she’s not my patient, and I’m not in a position to interview her and examine her.

What I can say, however, is that it’s very common for older adults to develop persisting fears, worries, and complaints that often strike their family members as irrational, paranoid, absurd, or ridiculous.

Why is this?

Among my own patients, I’ve found this is often related to underlying cognitive impairment. Meaning, a problem with memory or thinking that hasn’t yet been fully diagnosed by doctors. In some cases, this kind of complaint ends up being one of the very earliest signs of clinical dementia.

Lewy-Body dementia, in particular, is associated with visual hallucinations. But any process causing brain deterioration (Alzheimer’s, vascular dementia, etc.) can result in anxieties spiraling out of control, or persisting strange beliefs.

That said, it’s quite possible for an aging person to express such fears and not have it be dementia. Maybe there really is an animal in the house, or a person stealing your parent’s things. It’s also possible for people to develop confusion or false beliefs due a problem other than dementia, such as mental illness or delirium.

(For more in-depth information on the most common causes of paranoia and strange beliefs in older adults, see this article: 6 Causes of Paranoia in Aging & What to Do.)

Still, given your mom’s age and the fact you’ve noticed other signs of “thinking deterioration,” there’s a good chance that her persisting fear could be related to some chronic underlying cognitive impairment.

4 Things to try to help your mother

[Read more…]

How to Manage Sleep Problems in Dementia

by Leslie Kernisan, MD MPH

Sleep problems are common in Alzheimer’s and other dementias. They also commonly drive family caregivers crazy, because when your spouse or parent with Alzheimer’s doesn’t sleep well, this often means that you don’t sleep well.

To make matters even worse, not getting enough sleep can worsen the thinking or behavior of someone with dementia. Of course, this is true for those of us who don’t have Alzheimer’s as well: we all become more prone to irritation and emotional instability when we’re tired. Studies have also shown that even younger healthy people perform worse on cognitive tests when they are sleep-deprived.

Hence getting enough sleep is important, for people diagnosed with dementia, and for their hard-working caregivers. Now, sleep problems do often take a little effort to evaluate and improve. But as I explain below, research has found that it is often possible to improve sleep problems in dementia.

The key is to know what common causes to look for, and then come prepared to provide useful information to the doctor. In this article, I’ll cover:

Common causes of sleep problems in Alzheimer’s and other dementias,
How sleep issues should be evaluated
Proven approaches that help improve sleep in dementia
What to know about commonly tried medications for this problem

Common Causes of Sleep Changes and Problems in People with Dementia

[Read more…]

How to Plan for Decline in Alzheimer’s Dementia:
A 5-Step Approach to Navigating Difficult Decisions & Crises with Less Stress

by Leslie Kernisan, MD MPH

Q: My mother is 76 and has Alzheimer’s disease. She had a couple of unavoidable stays last year in the hospital (due to falls). This accelerated her decline due to delirium, which was treated as if she was just being an unruly and difficult patient. Once my sister and I understood what was going on due to this site’s information, we have been able to protect and support her.

Right now things are stable and quiet, so we are trying to plan ahead.

How should we go about planning for the years of decline my mother may experience before her actual last moments near death? It’s hard to imagine this possibility and I need help facing the (to me) not so obvious.

We have a will, power of attorney, and health care proxy in place.

A: Great question, and especially good that you’re taking advantage of a “quiet period” to address these issues.

It’s a little tricky to answer this question without knowing more about your mother’s current ability to participate in decision-making and in planning for her future care.

Since you say she’s declined after hospitalizations for falls and delirium, let me assume that she has moderate Alzheimer’s and can’t manage more than perhaps expressing some of what she likes and doesn’t like. (For more on the stages of Alzheimer’s and related dementias, see here.)

At this point, you’ve been through some health crises already, and you’ve seen her decline. You’ve also probably gotten a sense of just how many decisions have to be made on her behalf. Some are about her medical care and some are about other aspects of her life, like where she lives and how she spends her days.

Planning ahead is an excellent idea. Obviously, it’s simply not possible to anticipate and plan for every decision that will come up.

But let me offer you an approach that you can use both now as well as “in the heat of the moment” when specific issues arise. This is a framework to help you navigate all kinds of care decisions and future crises that you may encounter.

The following five steps will give you a foundation for anticipating, processing, and reacting to the complications and problems of later-stage Alzheimer’s, with less anxiety and more confidence. These steps are:

[Read more…]

4 Medications FDA-Approved to Treat Alzheimer’s & Other Dementias:
How They Work & FAQs

by Leslie Kernisan, MD MPH

If someone in your family has been diagnosed with Alzheimer’s or another dementia, chances are that they’ve been prescribed one of the “memory medications,” such as donepezil (brand name Aricept) or memantine (brand name Namenda).

But were they told what to expect, and how to judge if the medication is worth continuing?

I’ve noticed that patients and families often aren’t told much about how well these medications generally work, their side effects, and how to determine if it’s likely to help in their situation.

So in this post, I’ll explain how the four Alzheimer’s medications in wide use work. I’ll also address some of the frequently asked questions that I hear from older adults and families.

If someone in your family is taking one of these medications or considering them, this will help you better understand the medication and what questions you might want to ask the doctors. It’s especially important to understand the pros and cons if finances or medication costs are a concern.

I also have a video discussing this topic, along with newer discoveries in Alzheimer’s care and non-drug related approaches:

Note: This article is about those drugs that have been studied and approved to treat the cognitive decline related to dementia. This is not the same as treating behavioral symptoms (technically called “neuropsychiatric” symptoms) related to dementia, such as paranoia, agitation, hallucinations, aggression, sleep disturbances, wandering, and so forth. Until 2023, there were no drugs FDA-approved to treat the behavioral problems of dementia. The use of psychiatric medications, such as quetiapine and brexpiprazole (Seroquel and Rexulti, respectively), in dementia and is covered here: 5 Types of Medication Used to Treat Sundowning & Difficult Dementia Behaviors.)

Worried about the health & safety of an aging loved one? I explain how to address driving and other safety issues here: How to Help Your Parent with Memory Loss Be Safer (Even if They’re Resisting).

4 Oral Medications FDA-Approved to Treat Dementia

FDA-approved medications to treat Alzheimer’s and related types of dementia basically fall into two categories:

[Read more…]

4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory

by Leslie Kernisan, MD MPH

A few years ago, while I was at a family celebration, several people mentioned memory concerns to me.

Some were older adults concerned about the memory of their spouses. Some were adult children concerned about the short-term memory of their parents. And a few were older adults who have noticed some slowing down of their own memory.

“But you know, nothing much that can be done at my age,” remarked one man in his eighties.

Wrong. In fact, there is a lot that can and should be done, if you notice memory loss or thinking changes in yourself or in another older adult. And you should do it because it ends up making a difference for brain health and quality of life.

First among them: identify medications that make brain function worse.

This is not just my personal opinion. Identifying and reducing such medications is a mainstay of geriatrics practice. Among other reasons, we do find that in some people, certain medications are causing memory loss symptoms — or other cognitive symptoms — to be worse.

And the expert authors of the National Academy of Medicine report on Cognitive Aging agree: in their Action Guide for Individuals and Families, they list “Manage your medications” among their “Top 3 actions you can take to help protect your cognitive health as you age.”

Unfortunately, many older adults are unaware of this recommendation. And I can’t tell you how often I find that seniors are taking over-the-counter or prescription medications that dampen their brain function. Sometimes it’s truly necessary but often it’s not.

What especially troubles me is that most of these older adults — and their families — have no idea that many have been linked to developing dementia, or to worsening of dementia symptoms. So it’s worth spotting them whether you are concerned about mild cognitive impairment or caring for someone with full-blown Alzheimer’s dementia.

Every older adult and family should know how to optimize brain function. Avoiding problem medications — or at least using them judiciously and in the lowest doses necessary — is key to this.

And don’t give anyone a pass when they say “Oh, I’ve always taken this drug.” Younger and healthier brains experience less dysfunction from these drugs. That’s because a younger brain has more processing power and is more resilient. So drugs that aren’t such problems earlier in life often have more impact later in life. Just because you took a drug in your youth or middle years doesn’t mean it’s harmless to continue once you are older.

You should also know that most of these drugs affect balance, and may increase fall risk. So there’s a double benefit in identifying them, and minimizing them.

Below, I share the most commonly used drugs that you should look out for if you are worried about memory loss.

Featured Download: Get my free list of medications that can affect memory and thinking in aging adults. This handy PDF includes all the medications I usually check for. Click here to download.

The Four Most Commonly Used Types of Medications That Dampen Brain Function

[Read more…]

Cerebral Small Vessel Disease:
What to Know & What to Do

by Leslie Kernisan, MD MPH

Signs of cerebral small vessel disease. From Inzitari et al, BMJ. 2009 Jul 6;339:b2477. doi: 10.1136/bmj.b2477

This article is about the most common aging brain problem that you may have never heard of.

While leading a fall prevention workshop a few years ago, I mentioned that an older person’s walking and balance problems might well be related to the presence of “small vessel ischemic changes” in the brain, which are very common in aging adults. (This is also called “white matter disease.”)

This led to an immediate flurry of follow-up questions. What exactly are these changes, people wanted to know. Do they happen to every older adult? Is this the same as vascular dementia? And how they can best help their parents with cognitive decline?

Well, these types of brain lesions don’t happen to every older person, but they do happen to the vast majority of them. In fact, one study of older adults aged 60-90 found that 95% of them showed signs of these changes on brain MRI.

In other words, if your older parent ever gets an MRI of the head, he or she will probably show some signs of these changes.

So this is a condition that older adults and families should know about. Furthermore, these changes have been associated with problems of consequence to older adults, including:

Cognitive decline,
Problems with walking or balance,
Strokes,
Vascular dementia.

Now, perhaps the best technical term for what I’m referring to is “cerebral small vessel disease.” But many other synonyms are used by the medical community — especially in radiology reports. They include:

White matter disease
Small vessel ischemic disease
Brain lesions
Periventricular white matter changes
Perivascular chronic ischemic white matter disease of aging
Chronic microvascular changes, chronic microvascular ischemic changes
Chronic microvascular ischemia
White matter hyperintensities
Age-related white matter changes
Leukoaraiosis

In this post, I will explain what all older adults and their families should know about this extremely common condition related to the brain health of older adults.

In particular, I’ll address the following frequently asked questions:

What is cerebral small vessel disease (SVD)?
What are the symptoms of cerebral SVD?
How is cerebral small vessel disease related to vascular dementia and cerebrovascular accidents?
What causes cerebral SVD?
How can cerebral SVD be treated or prevented?
Should you request an MRI if you’re concerned about cerebral SVD?

I will also address what you can do, if you are concerned about cerebral SVD for yourself or an older loved one.

[Read more…]

Q&A: What You Can Do if You’re Worried About “Incompetence”

by Leslie Kernisan, MD MPH

Q: My 87-year-old father lives alone. His house has become increasingly dirty, but he refuses to get help, even though I’m sure he needs it. I’m worried that he’s becoming incompetent and in need of elder care, but he doesn’t want to go see the doctor. What can I do?

A: This situation does come up a fair bit with aging parents and relatives. I’m sorry to say there usually are no easy solutions. But there definitely are things you can and should do, and it’s better to act sooner rather than later.

Let’s review what you can do. I’ll also explain what I’ve learned about “incompetence” over the years, and how doctors usually play a role in the evaluation of such older adults.

Then, I’ll share some thoughts on how older people and families can plan ahead, to avoid facing this kind of dilemma. And then last but not least, I share a few thoughts on taking care of yourself as you go through this.

The usual concern, for a person of this age, is that the person may have developed memory loss, or a dementia such as Alzheimer’s disease.

This is a pretty reasonable worry, since an estimated 30% of people aged 85+ have dementia. (Wondering about dementia vs Alzheimer’s? Here’s where I explain dementia and how it’s related to Alzheimer’s.)

And of course, if your older parent seems to be doing worse than before, when it comes to activities that require mental organization (such as keeping a house reasonably clean), that further increases the chance that some kind of brain deterioration is causing problems.

But, we should never start by jumping to the conclusion that someone has developed dementia and needs elder care.

[Read more…]

How We Diagnose Dementia: The Practical Basics to Know

by Leslie Kernisan, MD MPH

“Doctor, do you diagnose dementia? Because I need someone who can diagnose dementia.”

A man asked me this question recently. He explained that his 86 year-old father, who lived in the Bay Area, had recently been widowed. Since then the father had sold his long-time home rather quickly, and was hardly returning his son’s calls.

The son wanted to know if I could make a housecall. Specifically, he wanted to know if his father has dementia, such as Alzheimer’s disease.

This is a reasonable concern to have, given the circumstances.

However, it’s not very likely that I — or any clinician — will be able to definitely diagnose dementia based a single in-person visit.

But I get this kind of request fairly frequently. So in this post I want to share what I often find myself explaining to families: the basics of clinical dementia diagnosis, what kind of information I’ll need to obtain, and how long the process can take.

Now, note that this post is not about the comprehensive approach used in multi-disciplinary memory clinics. Those clinics have extra time and staff, and are designed to provide an extra-detailed evaluation. This is especially useful for unusual cases, such as cognitive problems in people who are relatively young.

Instead, in this post I’ll be describing the pragmatic approach that I use in my clinical practice. It is adapted to real-world constraints, meaning it can be used in a primary care setting. (Although like many aspects of geriatrics, it’s challenging to fit this into a 15 minute visit.)

Does this older person have dementia, such as Alzheimer’s disease? To understand how I go about answering the question, let’s start by reviewing the basics of what it means to have dementia.

5 Key Features of Dementia

A person having dementia means that all five of the following statements are true:

[Read more…]

Q&A: How to Diagnose & Treat Mild Cognitive Impairment?

by Leslie Kernisan, MD MPH

Q: I realize that I sometimes have difficulty connecting a name and a face. I presume that this is mild cognitive impairment.

On researching the topic online, I find a variety of suggestions for alleviating it. These include supplements (lipoic acid, vitamin E, omega 3s, curcumin), food choices (fish, vegetables, black and green teas), aerobic exercise, yoga, and meditation.

Do these actually help with mild cognitive impairment? What’s been proven to work?

A: It’s common for older adults to feel they’re having trouble with certain memory or thinking tasks as they get older.

I can’t say whether it’s mild cognitive impairment (MCI) in your particular case. But we can review what is known about stopping or slowing cognitive changes in people diagnosed with MCI.

First, let’s start by reviewing what MCI is, and how it’s diagnosed. Then I’ll share some information on the approaches you are asking about, as well as other approaches for treating MCI.

What is Mild Cognitive Impairment?

[Read more…]

4 Things to try to help your mother

Common Causes of Sleep Changes and Problems in People with Dementia

4 Oral Medications FDA-Approved to Treat Dementia

The Four Most Commonly Used Types of Medications That Dampen Brain Function

5 Key Features of Dementia

What is Mild Cognitive Impairment?

Disclaimer