Dr. Ashok Bharucha, MD

Behavioral disturbances are quite common over the course of dementia, and often are more difficult to manage than the cognitive changes. Several factors have to be considered in relation to every behavioral change: cognitive changes (forgetfulness, poor attention span, visuospatial problems, etc.), medical issues (urine or lung infection, poorly managed pain, bowel or bladder issues, loss of mobility, etc.), psychiatric issues (depression, anxiety, etc.), environmental factors (over- or understimulation, lack of structure/routine, environment that does not take into account the person's cognitive limitations, etc.), and caregiver approach to the problem. If there are no active medical issues, I would certainly explore how some of the other factors listed here may be playing a role, and may inform how to intervene. Although antidepressants are only modestly effective in the context of dementia, there are clearly individuals who respond well to them, just as there are individuals who also respond well to cognitive enhancers such as donepezil, rivastigmine, galantamine, or memantine. The key is a careful evaluation by a geriatrically trained professional to figure out what factors are contributing to the problem.

The answer depends partly on the stage of dementia in terms of what would be possible psychotherapeutically. Depression should certainly be fully evaluated to take into account medical factors/medications that may be related to it. Identifying pleasant activities that he would still be able to participate in would be helpful. Early in the course of the condition, supportive psychotherapy would be an important element of care. The evidence supporting the effectiveness of antidepressants in the context of dementia is not very compelling, but they are often used, and could make a big difference for some. The problem is that we do not know which antidepressants work for whom under what circumstances in the context of dementia. Given their relatively benign safety profile, I am inclined to use one if indicated.

It would depend on the reasons for the outburst. A psychiatric consultation would be a good starting point.

The effectiveness is the same for any antidepressant. What distinguishes them are side effect profiles and certain pharmacological properties.

Yes, I would strongly recommend a consultation.

Hi. Medications such as Xanax and others in its class are contraindicated in the elderly but there is a small group of people for whom other options do not work well. The best alternative might be an antidepressant such as Lexapro and gradually tapering off the Xanax. I would strongly recommend she be fully evaluated by a geriatrically trained psychiatrist before doing anything. Thanks.

Yes. Alcohol use disorder is listed as a category in the American Psychiatric Association's diagnostic manual as a disorder.

Hi, it would not be unusual to see a combination of anger and depression in such a situation. Most facilities do have access to counseling services. Perhaps she would be open to such. Her medical team could certainly pursue a general medical workup to evaluate possibility of depression, and consider appropriate medication intervention, if indicated.

A careful medical evaluation to identify potentially undiagnosed medical conditions, as well as the possible negative mood effects of current combination of medications would be the first prudent step. Older individuals respond as well to depression treatment, if not better, than adults with depression. There are many antidepressants as well as other treatments that could be helpful. In terms of behavioral approaches, regular exercise, regular sleep schedule, avoidance of alcohol, socialization, etc. are very important. Involvement of a geriatrically trained internist or psychiatrist would be helpful.

Hi, it really depends on the underlying cause, whether it's medical, medication- or substance-related, psychiatric, or cognitive. A psychiatric workup would be prudent because the treatment depends on the correct diagnosis.

She needs to be medically and psychiatrically evaluated. If she is not
willing to leave the house, you may need to call your county's mobile
crisis number to see if someone can come and evaluate her. Perhaps they can
find a way to have her evaluated in the ER first since it may take a while
before an appointment with a psychiatrist can be arranged. Thanks.

The most reliable sources might be the National Depression and Bipolar Alliance website and the National Institutes of Mental Health website. The National Library of Medicine (PubMed) often also has review materials that may be helpful.

Delusions can be caused by a long list of medical problems, medications, medication interactions, and psychiatric, as well as neurological problems. Ideally he needs to be seen by a psychiatrist who specializes in mental disorders of later life, but there are very few of them. You may wish to start by visiting his primary care doctor who might then make a referral to a neurologist as well for a dementia evaluation. It is important to rule out medical and neurological issues as well as medication interactions before deciding on a course of treatment.