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Depression, anxiety, irritability, and agitation are some of the most common mood and behavior problems that individuals with Alzheimer’s disease and dementia experience. In this final article of our three-part series, we discuss medications that can help with these problems. If you or a loved one is living with dementia, speak to your doctor for more information.
Depression and anxiety may be caused by psychological and biological factors.
There are few things as depressing and anxiety-provoking as being aware that one is losing one’s mind from Alzheimer’s or another neurodegenerative disease. Just worrying about dementia can cause depression and anxiety.
In addition, the pathology of Alzheimer’s disease and other dementias often causes the depletion of neurotransmitters, including serotonin, dopamine, and norepinephrine, whose levels are directly related to mood and calmness. Thus, whether because of an understandable emotional reaction to having a devastating brain disease or because of the disease process itself, depression and/or anxiety occur in more than half of individuals with Alzheimer’s disease and other causes of dementia.
Non-pharmacological therapy for depression and anxiety may be effective.
To begin, we start with non-pharmacological treatments for depression and anxiety. Aerobic exercise, meditation, and relaxation therapy are things that individuals can do for themselves to reduce their depression and anxiety. In fact, aerobic exercise may be as effective as many antidepressants that are prescribed today.
Support groups can be very helpful for improving mood and reducing anxiety. And talk therapy can be particularly effective for individuals whose problems are mainly due to the quite understandable psychological reaction to having memory loss and/or a diagnosis of Alzheimer’s disease.
Pharmacological therapy is also an option for depression and anxiety.
Although an exhaustive discussion of pharmacotherapy for depression and anxiety is beyond the scope of this article, we'll share the general principles and medications we find most effective for depression and anxiety in individuals with Alzheimer’s disease and other causes of dementia.
Many antidepressants and anxiolytics can cause cognitive impairment. We try hard to stay away from those classes of medications. For example, we never prescribe a benzodiazepine for individuals who already have cognitive impairment at baseline.
For patients with depression and/or anxiety, we use low doses of sertraline (Zoloft; usually 50 or 75 mg) or escitalopram (Lexapro; usually 10 or 20 mg), both of which improve depression, anxiety, and often irritability and agitation as well. There are many side effects of these selective serotonin reuptake inhibitors (SSRIs), though few in the low doses that we generally use. Side effects may include apathy, headaches, gastrointestinal upset, periodic limb movements during sleep, suicidality, and sexual dysfunction, along with many others. Note that this class of medications needs to be tapered down slowly if one wants to discontinue them.
For patients with depression and apathy, venlafaxine (Effexor) and bupropion (Wellbutrin, Forfivo) can be helpful in treating both symptoms. Headaches, nausea, insomnia, dizziness, anorexia, somnolence, mania, and suicidality are some of the possible side effects and reactions that can occur with these medications, which also should be tapered down slowly. Note that these stimulating antidepressants can actually worsen anxiety, so they should be avoided in individuals with anxiety.
Therapy may be most effective for irritability and agitation.
The first thing to say here is that we try not to use medications for irritability and agitation. We start by educating the family (or other caregivers) about the four Rs:
- Reassure the individual that everything is alright.
- Reconsider things from the individual’s point of view.
- Redirect the individual to an activity that decreases the agitation.
- Relax; the caregiver needs to relax when caring for the agitated individual, lest they escalate the situation with their own tone of voice and body language.
Next, we work hard to determine the underlying cause of the agitation. If the agitation is due to anxiety (or if we cannot determine the cause of the agitation), we use sertraline (Zoloft) or escitalopram (Lexapro) as described above. If nighttime agitation is from a sleep disturbance, we work to treat the sleep disturbance (such as sleep hygiene or sleep cycle problems).
Rarely, we will use a low dose of risperidone (Risperdal) during the day or quetiapine (Seroquel) at night to treat the agitation. These atypical neuroleptics have many side effects, which include sedation, falls, heart attacks, strokes, and death. For this reason, we tend to avoid them and, when we do use them, we use low doses.
There is some emerging evidence for the use of dextromethorphan/quinidine (Nuedexta) for agitation in dementia and pimavanserin (Nuplazid) for psychosis in Parkinson’s disease dementia, so those medications could also be tried in the appropriate setting by the experienced clinician. These medications are not, however, FDA approved for this indication. But neither are the atypical neuroleptics.
© Andrew E. Budson, MD, 2019, all rights reserved.
LinkedIn Image Credit: 88studio/Shutterstock
References
Budson AE, O’Connor MK. Seven Steps to Managing Your Memory: What’s Normal, What’s Not, and What to Do About It, New York: Oxford University Press, 2017.
Budson AE, Solomon PR. Memory Loss, Alzheimer’s Disease, & Dementia: A Practical Guide for Clinicians, 2nd Edition, Philadelphia: Elsevier Inc., 2016.
