The Foundation of Treatment: Non-Pharmacological Interventions
Before resorting to medication, clinical guidelines strongly recommend exhausting all non-pharmacological strategies to address the behavioral and psychological symptoms of dementia (BPSD). These strategies are often more effective and safer for the elderly population than powerful drugs with serious side effects. The foundation of this approach is person-centered care, which focuses on understanding the individual’s needs, history, and triggers.
Common non-pharmacological strategies include:
- Environmental modification: Adjusting the person’s living space to minimize confusion and overstimulation. Examples include reducing clutter, ensuring adequate lighting, and controlling noise levels.
- Structured routines: Maintaining consistent daily schedules for activities, meals, and sleep to provide a sense of security and predictability.
- Sensory stimulation: Using music therapy, aromatherapy, or pet therapy to create a calming and positive environment.
- Personalized activities: Engaging patients in meaningful activities that tap into their former interests and skills, such as art, crafts, or gardening.
- Caregiver education and support: Training caregivers in effective communication techniques, distraction, and redirection strategies to de-escalate challenging behaviors.
Pharmacological Options and Their Complexities
When non-pharmacological approaches fail to manage severe symptoms that pose a risk to the patient or others, clinicians may consider medication. However, it is important to note that no traditional mood stabilizer is FDA-approved for the treatment of BPSD, and most are used off-label.
Anticonvulsants (Traditional Mood Stabilizers)
Anticonvulsants, a class of drugs often used as mood stabilizers, have been investigated for BPSD with limited and often contradictory results.
Carbamazepine: Some studies, often small, have shown promise in reducing aggression and hostility. However, the drug has significant side effects in the elderly, including sedation, dizziness, and gastrointestinal issues. It also carries risks of serious skin reactions and problematic drug interactions.
Valproic Acid (Divalproex Sodium): Despite being commonly used, extensive research, including a Cochrane review, has found no evidence that valproate effectively improves agitation in dementia. Furthermore, it increases the risk of harmful side effects like sedation, falls, and gastrointestinal problems.
Other Anticonvulsants: Evidence for other anticonvulsants like gabapentin, lamotrigine, and topiramate in treating BPSD is limited to case reports and small studies. The risk of side effects, including sedation and cognitive issues, compromises their utility.
Antipsychotics
Antipsychotics are sometimes used for severe symptoms like aggression and psychosis but come with a significant warning. The FDA has issued a black box warning stating that atypical antipsychotics are associated with an increased risk of stroke and death in older patients with dementia-related psychosis.
Brexpiprazole (Rexulti): Recently, the FDA approved brexpiprazole specifically for agitation associated with Alzheimer's dementia, marking the only medication with this indication. Despite this, its use requires careful consideration of the risks, including sedation, weight gain, and restlessness.
Antidepressants
Selective Serotonin Reuptake Inhibitors (SSRIs) are often prescribed for mood changes and anxiety in people with dementia.
Citalopram and Sertraline: These are frequently used and may offer some benefit for anxiety and agitation, particularly at lower doses. However, the evidence for their efficacy in BPSD is mixed, and side effects like QT prolongation with citalopram must be monitored.
Other Relevant Medications
Memantine: Used for moderate-to-severe Alzheimer's, memantine can sometimes help reduce aggression and psychosis with fewer side effects than antipsychotics.
Cholinesterase Inhibitors: Primarily for cognitive symptoms, drugs like donepezil may also slightly reduce agitation in some cases.
Comparing Key Pharmacological Approaches
| Medication Class | Primary Use in Dementia | Evidence for BPSD | Key Considerations & Risks |
|---|---|---|---|
| Anticonvulsants (e.g., Carbamazepine, Valproate) | Off-label mood stabilizing | Limited to mixed results; low for valproate | Sedation, dizziness, gastrointestinal issues, risk of falls; Valproate ineffective for agitation |
| Antipsychotics (e.g., Brexpiprazole, Risperidone) | Severe agitation, aggression, psychosis | Moderate for specific symptoms; Brexpiprazole FDA-approved for agitation | Black box warning for increased mortality, stroke risk, sedation, falls, weight gain |
| Antidepressants (SSRIs) (e.g., Citalopram, Sertraline) | Depression, anxiety, mood changes | Mixed evidence for agitation; requires dose monitoring | Potential for QT prolongation (citalopram), GI side effects, falls, takes weeks to work |
| Memantine (a glutamate regulator) | Moderate-to-severe Alzheimer's dementia | Some evidence for reducing aggression and psychosis | Better side-effect profile than antipsychotics, but still can cause confusion, dizziness, constipation |
| Cholinesterase Inhibitors (e.g., Donepezil) | Mild-to-moderate Alzheimer's disease | Some evidence of mild reduction in agitation | Side effects include nausea, diarrhea; effectiveness for BPSD varies widely |
Conclusion
There is no single answer to what is the best mood stabilizer for dementia patients? because there is no one-size-fits-all solution. The decision to use medication is a complex one, involving careful consideration of the specific symptoms, their severity, the patient’s overall health, and the potential for serious side effects. Non-pharmacological interventions are the first line of treatment, emphasizing a compassionate, person-centered approach. If medication becomes necessary, newer, FDA-approved options like brexpiprazole for specific symptoms or carefully chosen antidepressants may be considered, while older mood stabilizers like valproate have shown limited efficacy and higher risks. The ultimate goal is to improve the patient’s quality of life and safety by addressing the underlying causes of their distress, rather than simply suppressing symptoms.
For more information on non-pharmacological strategies, the Alzheimer's Association provides comprehensive resources and support for caregivers and families.
