This page will discuss:
- Medications recommended for managing the symptoms associated with dementia
- Medications to avoid in people with cognitive problems
Managing the changes associated with dementia requires a thoughtful approach. Any dramatic or sudden change in cognition, movement or behavior should be evaluated for a medical condition that may require treatment, such as an infection or pain. Untreated concurrent medical problems can lead to behavioral problems, especially if the person with dementia is having difficulty communicating.
Once a medical condition is ruled out, attempts to manage the symptoms with nondrug interventions is generally recommended first before using medications.
While medications can be very helpful, some medications can cause new problems and should be avoided. Others might need their doses to be adjusted to provide benefits or to reduce side effects. Some medications may no longer be needed or alternative treatments, including non-drug strategies, might be safer and more effective for you.
When medications are indicated, the general advice is to:
- Start at a low dose and then increase slowly based on the patient’s response in order to maximize benefits and minimize side effects.
- Avoid medications that may worsen memory and thinking or increase confusion, since people with cognitive problems may be particularly sensitive to the effects of certain medications.
- Avoid drug interactions that may interfere with medications used to treat cognitive problems.
- Make one medication change at a time to understand its effect.
It is important to see your doctor regularly while taking these medications. As the disease progresses and symptoms change, the medications or doses may need to change, or the medications might stop working or need to be stopped. Please consult with your doctors before making any changes to your medications and tell them about all medications you are taking, including prescription, non-prescription, vitamins, supplements and herbals.
Overview of Medications for People with Cognitive Impairment
Current medications can’t cure Alzheimer’s disease or other dementias, but they might be able to slow it down and make it easier to live with. They may relieve symptoms related to memory, thinking, languageand other thought processes. In addition, they may also help with mood, agitation and other behavioral issues.
Medications may not work for everyone. People respond very differently to medications.
- Sometimes the medications can lead to improvement in memory, cognition or behavior.
- Sometimes they may not make a big difference, but memory, cognition or behavior may not decline or worsen as fast as without medications.
- Sometimes the medications don’t work, have problematic side effects or seem to make things worse.
- Usually the side effects go away after a few days, or the dose may need to be adjusted.
While these medications may cause side effects, many people are able to take them without problems.
Commonly Used Medications for Persons with Cognitive Impairment
| Drug Name (Brand Name) | Generic Available | Uses | Possible Side Effects |
| Donepezil (Aricept®) | Yes | All stages of dementia (not recommended in FTD) | Nausea, diarrhea, vomiting, upset stomach, lack of hunger, weight loss or low heart rate. Other less common problems are feeling tired, having trouble sleeping, vivid dreams or muscle cramps. |
| Rivastigmine (Exelon®) | Yes | All stages of dementia (not recommended in FTD) | |
| Galantamine (Razadyne®) | Yes | All stages of dementia (not recommended in FTD) | |
| Memantine (Namenda®) | Yes | Moderate to severe stages of dementia; often used in combination with one of the drugs above (not recommended in FTD) | Headache, dizziness, confusion or constipation |
While none of these drugs are approved for use in mild cognitive impairment (MCI), some clinicians may prescribe them.
Treatment for Common Conditions and Symptoms
Below are common conditions and symptoms that persons with dementia often experience. For each condition, we list common medications to avoid because they may worsen memory and thinking, have problematic side effects or cause other problems, and safer alternatives to consider, both drug and non-drug interventions.
Anxiety
Common medications for anxiety include diazepam (Valium®) and other drugs in this class called benzodiazepines. Unfortunately, in older adults, these medications often cause more confusion, excessive sedation or drowsiness, and increase the risk of falls. The table below describes common drugs to avoid, safer non-drug strategies and alternate medications to consider.
Condition
Anxiety
Common Drugs to Avoid
Benzodiazepine antianxiety drugs such as diazepam (Valium®); lorazepam (Ativan®); alprazolam (Xanax®); clonazepam (Klonopin®); temazepam (Restoril®); chlordiazepoxide (Librium®) and anticholinergic medications such as hydroxyzine (Atarax®).
If these medications must be used, they should be used at the lowest effective dose for the shortest duration to minimize adverse effects.
Why?
These medications can cause confusion and increase your risk of falls. Because it takes your body a long time to clear these drugs, these effects can carry into the day after you take the medication or accumulate over time. When used in combination with alcohol and other sedating drugs, the effects can be very powerful and lead to excessive sedation, drowsiness and dizziness.
Non-Drug Strategies
- Relaxation techniques, deep breathing exercises, scheduled activities and strategies to improve communication and interaction to reduce anxiety (see ).
- Be aware of and sensitive to fears, perceived threats, and frustration with ability to communicate needs and wants.
- Create a calm, safe, quiet environment with comfortable temperature and minimizing noise, glare and background distractions.
- Ensure personal comforts by checking for pain, hunger, thirst, infection, constipation, diarrhea, full bladder, fatigue.
Safer Medications to Consider
Certain antidepressants can help with anxiety such as citalopram (Celexa®), escitalopram (Lexapro®), venlafaxine (Effexor®), mirtazapine (Remeron®), or buspirone (Buspar®).
Incontinence
Some of the common drugs used for incontinence can worsen the chemical imbalance that is associated with memory problems and counteract the effects of most memory medications. Being sure of the cause of the incontinence is important. For example, it could be due to a urinary tract infection, high blood sugar causing frequent urination, diuretic medicationsor, in men, an enlarged prostate. Identifying and treating underlying causes of incontinence is important to preventing and managing incontinence.
Condition
Incontinence
Common Drugs to Avoid
Bladder agents that have strong anticholinergic properties such as oxybutynin (Ditropan®, Oxytrol®); tolterodine (Detrol®); fesoterodine (Toviaz®), darifenacin (Enablex®)
Why?
These medications can cause confusion, constipation, dry mouth, blurred vision, dizziness and increase your risk of falls. They counteract the effects of most memory medications.
Non-Drug Strategies
- Treat the underlying cause (e.g., possible infection, high blood sugar, constipation, enlarged prostate in men) or certain medications that can cause incontinence (e.g., diuretics).
- Avoid intake of drinks and foods that stimulate the bladder such as caffeinated beverages, chocolate, spicy foods or citrus fruit.
- Regular, timed trips to the restroom may avoid the bladder becoming too full and having accidents.
- Pelvic exercises.
- Use of absorbent products such as adult diapers.
- Surgeries or catheters.
Safer Medications to Consider
The incontinence medications trospium (Sanctura®), solifenacin (Vesicare®) and mirabegron (Myrbetriq®) are less likely to affect memory and thinking and also less likely to interfere with memory medications.
Insomnia
Many prescription and non-prescription or over-the-counter medications (e.g., diphenhydramine [Tylenol PM®, Advil PM®, Benadryl®]) can worsen the chemical imbalance common in memory problems and cause significant confusion and a risk of falls. Some of these medications can also counteract the effects of memory medications. In addition, identifying and treating underlying causes of insomnia or disturbed sleep such as depression, anxiety, high blood sugar leading to frequent urination or use of medications that affect sleep is important to managing insomnia.
Condition
Insomnia
Common Drugs to Avoid
Diphenhydramine containing products (e.g., Benadryl®, Tylenol PM®, Advil PM®), sleep medications such as zolpidem (Ambien®), eszopiclone (Lunesta®), zaleplon (Sonata®), hydroxyzine (Atarax®), doxylamine (Unisom®) and benzodiazepine drugs such as temazepam (Restoril®), lorazepam (Ativan®); alprazolam (Xanax®); chlordiazepoxide (Librium®); clonazepam (Klonopin®) and diazepam (Valium®)
Why?
Diphenhydramine, hydroxyzine and doxepin can cause confusion, constipation, dry mouth, blurred vision, dizziness and increase your risk of falls. It counteracts the effects of most memory medications. The other drugs can worsen memory, thinking, cause excessive sedation, drowsiness and dizziness and increase your risk of falls. When used in combination with alcohol and other sedating drugs, the effects can be very powerful and lead to excessive sedation, drowsiness and dizziness.
Non-Drug Strategies
- Treat potential underlying causes of insomnia including depression, anxiety, pain, sleep apnea and other conditions.
- Good sleep hygiene includes having a regular sleep/wake cycle with exposure to bright light during the day and a dark, quiet sleeping area at night.
- Being active during the day and avoiding daytime naps.
- Soothing night time routines including warm baths or warm milk.
- Avoiding stimulating foods or drinks with caffeine late in the day or at bedtime.
- Take medications that may cause insomnia or disrupt sleep in the morning instead of later in the day.
Safer Medications to Consider
- Melatonin is a dietary supplement that can help with your sleep/wake cycle when taken at bedtime.
- Alternative prescription medications include ramelteon (Rozerem®), low dose trazodone (Oleptro®, Desyrel®) or low dose mirtazapine (Remeron®).
Depression
Currently, SSRIs (selective serotonin reuptake inhibitors) are the most commonly prescribed medications for mood symptoms in persons with dementia. SSRIs may be useful in reducing the aggressive impulses, poor impulse control, apathy and improving mood in people with dementia. However, some antidepressants such as paroxetine (Paxil®), amitriptyline (Elavil®) and nortriptyline (Pamelor®) are other common antidepressants which may worsen the cholinergic imbalance in the brain and worsen memory, thinking or the effectiveness of memory medications. Fluoxetine(Prozac®) is sometimes used, but it has many drug interactions and stays in the body for a long time.
Examples of SSRIs include:
- citalopram (Celexa®)
- escitalopram (Lexapro®)
- fluoxetine (Prozac®)
- sertraline (Zoloft®)
- vortioxetine (Trintellix®)
Other antidepressants (not SSRIs) that may be useful:
- bupropion (Wellbutrin®)
- duloxetine (Cymbalta®)
- mirtazapine (Remeron®)
- trazodone (Desyrel®)
- venlafaxine (Effexor®)
Condition
Common Drugs to Avoid
Paroxetine (Paxil®), amitriptyline (Elavil®), nortriptyline (Pamelor®, Aventyl®), desipramine (Norpramin®), imipramine (Tofranil®).
Why?
These antidepressants have anticholinergic properties which can worsen memory, thinking or counteract the effectiveness of memory medications.In addition, they can cause confusion, constipation, dry mouth, blurred vision, dizziness and increase your risk of falls.
Non-Drug Strategies
- Treat potential underlying causes of depression including nutrient or vitamin deficiency, low thyroid function, or certain medications that can cause symptoms of depression.
- Physical activity and good sleep hygiene can help with mood and symptoms.
- Therapy and counseling can help with mood.
Safer Medications to Consider
The antidepressants listed above are safe medications to consider. It often requires adjusting the dose or perhaps trying other antidepressants and combinations of antidepressants to find the right medications that work.
Pain
Narcotics and opiates such as codeine, hydrocodone (Vicodin®, Norco®), oxycodone (OxyContin®), morphine (MS Contin®, Roxanol®), fentanyl (Duragesic®) and hydromorphone (Dilaudid®) are often used for pain relief. Unfortunately, they often can cause confusion and falls in older adults. Muscle relaxants such as cyclobenzaprine (Flexeril®); carisoprodol (Soma®); methocarbamol (Robaxin®); metaxalone (Skelaxin®) can leave you feeling groggy and confused, increase your risk of falls, cause constipation, dry mouth, and problems urinating and counteract the effectiveness of memory medications. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil®, Motrin®); naproxen (Aleve®), indomethacin (Indocin®); ketorolac (Toradol®); sulindac (Clinoril®), etodolac (Lodine®), diclofenac (Voltaren®) can increase the risk of bleeding stomach ulcers, raise your blood pressure, affect your kidneysand worsen heart failure when used long term. If these medications must be used, they should be used at the lowest effective dose for the shortest duration.
Condition
Pain
Common Drugs to Avoid
Narcotics such as hydrocodone, oxycodone and morphine; muscle relaxants such as cyclobenzaprine, carisoprodol; NSAIDs such as ibuprofen, naproxen should be avoided if possible.If these medications must be used, they should be used at the lowest effective dose for the shortest duration to minimize adverse effects.
Why?
Narcotics and muscle relaxants can worsen memory and thinking, increase the risk of falls and cause constipation, dry mouth, sedation, dizziness and drowsiness. NSAIDs can increase the risk of bleeding, affect blood pressure, kidneys and worsen heart failure.
Non-Drug Strategies
- Physical therapy, acupuncture/acupressure, warm or cold compresses, heating pads, relaxation and meditation techniques, gentle massage or stretching.
- Local and topical therapy (compresses, massage, ointments, creams and gels) usually are not absorbed in great amounts to affect memory and thinking.
Safer Medications to Consider
- Regularly scheduled acetaminophen (Tylenol®) can be helpful. Significant alcohol history or any decrease in liver function must be considered in determining dosage and length of therapy.
- Certain antidepressants such as duloxetine (Cymbalta®), mirtazapine (Remeron®), venlafaxine (Effexor®) may also be helpful for both pain and mood.
Hallucinations, Delusions, Severe Agitation or Aggression
Antipsychotic medications block the effects of dopamine, a chemical messenger in your brain that can increase hallucinations and delusions (false beliefs) and can alter rational thought. Low doses of these medications can help manage aggressive, irrational and compulsive behaviors that may develop in persons with dementia, more commonly with frontotemporal dementia or dementia with Lewy bodies. The potential benefit of antipsychotics must be weighed against potential risks including weight gain, slowing of movement and thinking, accelerating heart disease and, in rare instances, death. Typical or first-generation antipsychotics such as haloperidol (Haldol®) are associated with muscle problems and should be avoided in people who already experience muscle stiffness or trembling.
Can other interventions be used?
Understanding and treating the underlying cause of hallucinations or agitation is preferred. These behaviors can be due to infection, pain, medications that cause hallucinations or worsen mood and memory, environmental factors or social factors. Non-drug interventions involving physical therapy, music therapy, aquatic therapy, regularly scheduled activities, addressing or minimizing environmental factors such as temperature, noise, etc. and social factors such as how to talk to and engage the patient, introducing them to new caregivers or routines, etc.) can be helpful.
Are there safer medications to consider?
Memory medications and antidepressants can be helpful with hallucinations and agitation and are considered first-line. Atypical or second-generation antipsychotics are used when the first-line medications do not work. While they are safer alternatives to typical antipsychotics for persons with dementia, second-generation antipsychotics do carry similar risks as are typical of first-generation antipsychotics but with less frequency. Therefore, they should be used at the lowest effective dose for the shortest duration.
Examples of atypical antipsychotic medications include:
- quetiapine (Seroquel®)
- risperidone (Risperdal®)
- aripiprazole (Abilify®)
- olanzapine (Zyprexa®)
- clozapine (Clozaril®)
Condition
Hallucinations, delusions, severe agitation or aggression
Common Drugs to Avoid
Typical or first-generation antipsychotics such as haloperidol (Haldol®), chlorpromazine (Thorazine®), thioridazine (Mellaril®), perphenazine (Trilafon®) and others.
Why?
These medications can worsen memory and thinking, worsen movement and increase the risk of falls, increase the risk of stroke and death.
Non-Drug Strategies
- Treating potential underlying causes of hallucinations or agitation is preferred.These behaviors can be due to infection, pain, medications that cause hallucinations or worsen mood and memory, environmental factors or social factors.
- Create a calm, quiet environment that maintains personal comfort (e.g., lighting, temperature, noise, reflections).
- Physical therapy, music therapy, aquatic therapy, regularly scheduled activities.
- Addressing social factors and providing good communication skills such as how to talk to and engage the patient, introducing them to new caregivers or routines, etc.can be helpful.
- Avoid or stop certain medications that may be causing hallucinations, delusions, agitation or aggression.
Safer Medications to Consider
- Memory drugs and antidepressants are first-line treatments and can be very helpful with few adverse effects.
- Atypical or second-generation antipsychotics listed above are second line and should be used at the lowest effective dose for the shortest duration to minimize adverse effects.
Medication Resources
- 30 Years On, Are We Winning the Fight Against Alzheimer’s?
- Safe Use of Medicines for Older Adults
- How Is Alzheimer's Disease Treated?
- The 2019 American Geriatrics Society Updated Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults
- Polypharmacy issue of Clinics in Geriatric Medicine (2017)
- The Rise of Pseudomedicine for Dementia and Brain Healthpublished inJAMA (2019)
- Watch Out for False Promises About So-Called Alzheimer’s Cures published by the US Food & Drug Administration (FDA)
- Information on complementary and alternative medicine (CAM)
