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From: "Jonathan Silver" <SILVERJ@cpmail-nz.cis.columbia.edu>
Date: Wed, 6 Dec 1995 21:59:50 EST
Subject: Behavioral dyscontrol in patients with traumatic brain injury
I'd like advice in treating a mid thirties male patient who as a result of a severe motor vehicle accident some years ago became brain injured and psychotic and was institutionalised. His treatment has revolved around his behavior dyscontrol and various meds have been tried with minimal success. These include the usual -- carbemazepine, valproate, propranolol and even thiorodazine. A problem that surfaces occasionally and has of late has been an especially vexing one is that of his head banging.Agitated behavior is very common after TBI. The meds you listed above may often be helpful, but you must be sure that adequate dosages are used -- especially for propranolol, where the dosage should be increased to 640-800 mg/day and response may take several weeks. Other options include buspirone and SSRIs, especially if there is mood lability present. If psychosis is prominent, I would first try risperidone, reserving clozapine as a last-choice, but often effective, option (problems include anticholinergic side-effects and lowering of seizure threshold). For further info, see:--Anjan Chatterjee MD
Silver JM, Yudofsky SC: Aggression, in Neuropsychiatry of Traumatic Brain Injury, American Psychiatric Press, 1994
Yudofsky SC, Silver JM, Hales RE: Treatment of Aggressive Disorders, in American Psychiatric Press Textbook of Psychopharmacology, American Psychiatric Press, 1995
Date: Wed, 06 Dec 1995 17:27:56 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: Behavioral dyscontrol in patients with brain injury
The literature demonstrates that naltrexone can be helpful in self-injuring mentally retarded patients. Clinically, it can also help dissociative or borderline patients who compulsively self-mutilate.
Date: Thu, 7 Dec 95 0:37:34 EST
From: Max Mastellone <mastello@pilot.njin.net>
Subject: Behavioral dyscontrol in patients with brain injury
Have all medical causes of this behavior (such as tinnitus, otitis media, and headaches) been ruled out? These are sometimes behind the behavior in severe and profoundly mentally retarded clients who cannot otherwise express their discomfort. If so, then a strong behavior modification program is in order.
From: Charles.Enzer@UC.Edu (Charles Hart Enzer, M.D.)
Date: Thu, 07 Dec 1995 23:30:39 -0500 (EST)
Subject: Behavioral dyscontrol in patients with traumatic brain injury
The plan of treatment by the behaviorist needs to include:
From: "Jonathan Silver" <SILVERJ@cpmail-nz.cis.columbia.edu>
Date: Fri, 8 Dec 1995 13:02:09 EST
Subject: Behavioral dyscontrol in patients with traumatic brain injury
Propranolol was tried. Unfortunately, beyond 180 mg/day, I began to run into troublesome bradycardia (< 50 bpm). Interestingly enough I seem to run into this bradycardia problem a lot of the time and have only been able to cross 200 mg/day occasionally.I think there are the following options available:--Anjan Chatterjee MD
Date: 08 Dec 95 20:12:28 EST
From: "Thomas A. Connell, M.D." <71571.3346@compuserve.com>
Subject: Behavioral dyscontrol in patients with brain injury
While clinical ancedotes have supported it, the actual data supporting the effectiveness of naltrexone for self-injurious behavior has been controversial at best. The most recently published report has argued against it:
Willemsen-Swinkels SH, Buitelaar JK, Nijhof GJ, van England H. Failure of naltrexone hydrochloride to reduce self-injurious and autistic behavior in mentally retarded adults. Arch Gen Psychiatry 1995, 52: 766-773.
From: "Jonathan Silver" <SILVERJ@cpmail-nz.cis.columbia.edu>
Date: Sat, 9 Dec 1995 23:05:03 EST
Subject: Behavioral dyscontrol in patients with brain injury
Clonidine has been used in autistic children, and some have used it for more acute aggression in patients with brain injury (but I know of no publications). It theoretically could be helpful -- and sedating. One advantage would be the patch, eliminating the need for PO meds.
From: chatta01@popmail.med.nyu.edu (Anjan Chatterjee MD)
Date: Sun, 14 Jan 1996 12:58:52 -0500
Subject: Behavioral dyscontrol in patients
I have used clonidine for impulsive aggressive behavior with some succcess.
From: MKomrad@aol.com
Date: Wed, 22 May 1996 22:24:36 -0400
Subject: Behavioral dyscontrol in patients with organic problems
Cold-wet-sheet packs work wonders for agitation. Almost nobody does them anymore. We had a great speciality in this at my hospital at one time. We can still do it if necessary.
Buspirone is a good possibility (up to 80 mg/day) for treating agitation in very aggressive patients, particularly those with underlying organic problems -- e.g. the elderly or mentally retarded. An alternative is a beta-blocker such as Inderal LA (up to 420 mg/day).
Date: Sat, 12 Apr 1997 20:27:56 -0400
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: Agitation in Alzheimer's
Regan and Gordon report, in a letter to the editor, on the successful use of gabapentin for the control of agitation in a 68-year old female nursing home resident with episodic agitation and violence toward staff members. 300 mg were administered twice a day, the patient improved, and the patient's haloperidol was able to be reduced from 2 mg/day to 0.5 mg/day:
Regan WM, Gordon SM. Gabapentin for behavioral agitation in Alzheimer's disease. J Clin Psychopharm 1997, 17, 59-60.
Date: Thu, 12 Jun 1997 16:35:44 -0700 (PDT)
From: Julie Ann Dopheide <dopheide@hsc.usc.edu>
Subject: Behavioral dyscontrol in patients with cerebral palsy
We have experienced success using carbamazepine to treat aggression, impulsivity and mood instability in patients with cerebral palsy. My experience is anecdotal, however, carbamazepine has literature support for treatment of such symptoms in general "organic mood disorder patients".
Date: Thu, 11 Sep 1997 09:07:54 -0400
From: Bonnie Szarek <Bszarek@harthosp.org>
Subject: Agitation in Alzheimer's
Geriatric psychiatrists at our facility have found trazodone helpful in managing agitation. They generally give it in divided doses throughout the day, sometimes with additional prn orders; average dose: 150 mg/day.
More recently one of our geriatric psychiatrists has started using gabapentin and found it helpful. These are open clinical trials, not controlled studies.
Date: Thu, 11 Sep 1997 07:56:23 -0700
From: Stephen Nagy <snagymd@pol.net>
Subject: Agitation in Alzheimer's
While I have mostly been underwhelmed by the efficacy of buspirone and overwhelmed by its cost, I have seen a few demented patients with agitation who have responded superbly to 5 mg tid. Please note that since buspirone is a partial agonist, it may have a good effect at a low dose and not work as well if the dose is raised.
Another group of patients does very well, in my experience, with HS dosing of trazodone. I had one wiry little old fellow who took 400 mg per day, with no appreciable side-effects, but with a significant decrease in agitation.
Each is worth a try.
Date: Thu, 11 Sep 1997 12:45:37 -0400
From: Whit Garberson <jwgg@world.std.com>
Subject: Agitation in Alzheimer's
A couple of general observations from working with a large number of agitated and demented seniors in mostly nursing home settings in recent years:
Trazodone is still a very useful medication but has two potential disadvantages:
So it remains useful as a sleep aid, or as an anti-agitation medication in nonambulatory patients, but may not be the best choice for others.
Our group has been using more and more fluvoxamine instead. Fluvoxamine appears to have decent agitation-reduction *and* antidepressant effects even with quite conservative dosing, and it can often be an effective sleeper as well. We usually start with 25 mg at hs and increase in 25 mg increments q 3-4 days until we see results or reach a maximum of maybe 75 mg bid in frail elders. In a few cases, where insomnia was stubborn, we've augmented the fluvoxamine with trazodone 25-50 mg at hs with good results.
(I've heard a few testimonials about using nefazodone or mirtazapine for agitation, but have no real 1st-hand knowledge.)
I am convinced that lorazepam and other benzodiazepines frequently do more harm than
good for agitation secondary to dementia. They can promote disorientation and
confusion (themselves a major source of agitation), ataxia, and
disinhibition -- thereby increasing falls, aggression, and wandering. To say
nothing of tolerance, addiction, rebound, and (alas) regulatory issues.
(Of course benzodiazepines may be very helpful if prescribed for nursing staff.
)
But it's
important to differentiate anxiety disorders from agitation.
Adding small doses of risperidone (0.25 to 1.5 mg a day in divided doses) is usually a successful 2nd line of defense after trying a sedating antidepressant. Lately, our psychiatrists have been using olanzapine in similarly careful doses with good (possibly better) results, but this is pretty recent.
Only one of my nursing home patients (who had a great deal of organic damage from alcohol as well as Guillain-Barre syndrome) has ever required an estrogen patch; this after 80 mg of fluoxetine failed to tame his increasingly unmanageable sexual aggression. The combination worked beautifully, however.
Lastly -- and I promise I'll stop now -- I've been *amazed* to see wonderful behavioral responses to narcotic analgesics in patients whose agitation appeared to stem not just from dementia but from an undiagnosed (or underappreciated) chronic pain syndrome. I suspect chronic pain is a good deal more common than generally acknowledged and needs to be added to the boilerplate list of conditions to rule out (delirium, infection, bowel impaction, dehydration, etc.) in folks who are old and physically frail.
From: "Kevin Gray" <jahsteel@cyberramp.net>
Subject: Agitation in Alzheimer's
Date: Thu, 11 Sep 1997 13:28:47 -0500
I would recommend a trazodone trial first. It has a biphasic metabolism and a short t 1/2 and often needs dosing as bid or tid and qhs (and repeat dosing during the night may also be needed):
Sultzer DL, Gray KF, Gunay I, et al: A double-blind comparison of trazodone and haloperidol for treatment of agitation in patients with dementia. American J Geriatric Psychiatry 5: 60-69, 1997.
Using progestins [instead of estrogen] avoids the secondary sex changes in male patients and is preferred:
Weiner MF, Denke M, Williams K, et al: Intramuscular medroxyprogesterone acetate for sexual aggression in elderly men [letter]. Lancet 339: 1121-1122, 1992.
Date: Fri, 12 Sep 1997 12:18:45 +1200
From: david.menkes@stonebow.otago.ac.nz (David Menkes)
Subject: Agitation in Alzheimer's
We've found buspirone very useful in "assaultive dementia".
From: "Sanjeev K Singhal MD" <sanju@vidnet.net>
Subject: Agitation in Alzheimer's
Date: Thu, 11 Sep 1997 20:05:03 -0500
I see a number of patients with dementia and agitation. I use trazadone (watch for anticholinergic effects and orthostasis) by starting in the morning, afternoon, and around 4-5 pm (prior to sundowning if the patient is experiencing that). I use trazadone at night only if there is night time agitation or insomnia. I go up to a total of about 150 mg a day.
I have also used low dose risperidone, particularly when agiatation is manifest as screaming, throwing things, banging, etc.
I worked earlier with Mark Kunik at Baylor in Houston who has developed a scale for measurement of agitation in dementia.
He also finds buspirone useful in agitation in the elderly.
From: "Kevin Gray" <jahsteel@cyberramp.net>
Subject: Irritability in Alzheimer's
Date: Sun, 19 Oct 1997 10:30:30 -0500
Irritability is a clear "symptom" of Alzheimer's and one we are often asked to treat. Sertraline 50-100 mg is good for irritability and mood reactivity in non-psychotic, early stage Alzheimer's patients.
From: "Kevin Gray" <jahsteel@cyberramp.net>
Subject: Irritability in Alzheimer's
Date: Fri, 14 Nov 1997 11:20:41 -0600
I prefer sertraline for these patients to avoid the extreme CYP450 effects as well as the anticholinergic effects of paroxetine. Trazodone is also a useful "tonic" for calming and sleep in these patients.
Date: Wed, 03 Dec 1997 17:20:15 -0500
From: Frances Stewart <fstewart@med.navy.mil>
Subject: Agitation in Alzheimer's
Here are three studies on light therapy in dementia:
This study examined whether exposure to bright light treatment would reduce agitated behavior in institutionalized elderly subjects. Six demented elderly subjects (mean age = 89.2 years) living in a skilled nursing facility were studied. Light (2500 lx) was administered for 2 hours in the morning for two 10-day periods. The Bliwise Agitation Behavior Rating Scale was used to rate agitated behavior once every 15 min between 16:00 h and 20:00 h during 3 days of baseline, the light treatment periods, and 5 days of posttreatment follow-up evaluation. The entire protocol was then repeated in an ABABA design. A planned comparison revealed a significant difference between light treatment days and nontreatment days, with less agitation being observed on treatment days. The study suggests the efficacy of the clinical use of bright light treatment to reduce agitation.
Fourteen inpatients with dementia showing sleep and behavior disorders (average age = 75 years), and 10 control elderly people (average age = 75 years) were carefully observed for 2 months. Four weeks of morning light therapy markedly improved sleep and behavior disorders in the dementia group. The measurement of sleep time and the serum melatonin values suggests that sleep and behavior disorders in the dementia group are related to decreases in the amplitude of the sleep-wake rhythm and decreases in the levels of melatonin secretions. Morning light therapy significantly increased total and nocturnal sleep time and significantly decreased daytime sleep time. These results indicate that morning bright light is a powerful synchronizer that can normalize disturbed sleep and substantially reduce the frequency of behavior disorders in elderly people with dementia.
Light is known to be an important modulator of circadian rhythms. We tested the hypothesis than an enduring increase in the daytime environmental illumination level improves rest-activity rhythm disturbances in demented patients. Actigraphy was performed before, during, and after 4 weeks of increased illumination in the living rooms of 22 patients with dementia clinically diagnosed as probable Alzheimer's disease, multi-infarct dementia, dementia associated with alcoholism, or normal pressure hydrocephalus. The results indicated that during increased illumination, the stability of the rest-activity rhythm increased in patients with intact vision, but not in visually impaired patients.
From: "James W. Hawkins" <jwh@creative.net>
Subject: Agitation in Alzheimer's
I have had some good success using gabapentin (300 mg qd to 900 mg tid) in dementing patients who are agitated or aggressive.
Date: Fri, 20 Mar 1998 14:33:41 -0500
From: Bonnie Szarek <Bszarek@harthosp.org>
Subject: Agitation in Alzheimer's
Psychiatrists in our geriatric service have used gabapentin for treating agitation or aggression for patients with dementia, generally with positive results. Doses usually range from 300 mg qd to 600 mg tid with a median dose of 500 mg/day.
From: "Kevin Gray" <jahsteel@cyberramp.net>
Subject: Agitation in Alzheimer's
Date: Sat, 11 Apr 1998 10:02:53 -0500
At the American Association of Geriatric Psychiatry meeting last month, Jeff Cummings presented some interesting data on the use of metrifonate (and theoretically, other cholinesterase inhibitors) for agitation in Alzheimer's.
Date: Sat, 17 Apr 1999 21:01:54 -0700
From: "James W. Hawkins" <jwhsfo@pacbell.net>
Subject: Agitation in dementia
In the past you have sent several posts pertaining to the use of gabapentin to treat agitation in dementia patients. Has your overall experience mirrored your early results? How do you typically titrate the dose?I usually start with 100 mg tid unless the patient is very frail, and then I start at 100 mg qAM. I titrate up the dose -- to a maximum of 3600 -- over a period of weeks or longer. My current impression is that gabapentin is good for folks with agitation or aggression who have a bona fide dementia but without a pre-existing mood disorder as well as for patients whose primary problem is dementia and agitation after a traumatic brain injury. It is my clinical impression that it does not work in patients with bipolar illness or a manic phase of schizoaffective disease or in patients who, after the onset of dementia or a brain injury, develop a mood disorder with mania (as evidenced by increased irritability and other signs of mania). In fact, this latter group of patients may get worse with gabapentin.
I've not had a patient develop edema as is mentioned by other recent messages.
Recently, I've been using more and more quetiapine for the second group of patients mentioned above -- and it seems to be well tolerated and effective (with far fewer side effects than I've seen with risperidone or olanzapine).
Gabapentin is a good drug but if the patient worsens (as opposed to does not get any better -- which I know is often a very fine distinction), it should, of course, be stopped directly.
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Dr. Bob is Robert Hsiung, MD,
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URL: http://www.dr-bob.org/tips/split/Behavioral-dyscontrol-in-p.html
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Web page copyright 1995-99 Robert Hsiung.