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Antidepressant Shows Benefits, and Risks, for Agitation of Alzheimer’s

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Agitation is a common problem in people in the more advanced stages of Alzheimer’s disease, but there are few effective treatments to deal with those who have it. Now a new study found that the antidepressant drug citalopram (brand names Celexa and Cipramil) can be effective in easing agitation in elderly people with dementia, though it carries some serious side effects that limit its usefulness.

The emotional distress, aggression, irritability, and disruptive and unpredictable outbursts typical of agitation pose dangers for patients and caregivers alike. It also increases stress for those affected and those who care for them, and can lead to depression in caregivers. Agitation is a common reason why those with Alzheimer’s must leave the home and be placed in a nursing home.

But good treatments for agitation are lacking. Antipsychotics are often given to ease the behavioral problems of dementia, though they carry serious side effects, including an increased risk of fatal heart attacks and strokes. Citalopram, a so-called SSRI, or selective serotonin reuptake inhibitor, that is usually prescribed to treat depression had shown some promise in earlier studies in easing the agitation of dementia.

So researchers set out to do a more rigorous study, looking at the medication’s effects on patients and caregivers. For the study, they recruited 186 men and women with Alzheimer’s from eight medical centers across the United States and Canada. All had problems with agitation, though none had serious depression.

The study participants were divided into two groups. One group received citalopram, at a starting dose of 10 milligrams a day. Over the next three weeks, the dose was increased to 30 milligrams a day. The other group, which served as controls, got a lookalike dummy pill. Neither doctors nor patients knew whether they are getting the real medicine or a placebo.

In addition, participants in both groups got a program of psychotherapy and counseling. The program included educational materials about agitation and dementia, a 24-hour helpline in cases of emergencies, and a 20- to 30-minute counseling session during regular clinic visits.

After nine weeks, those who’d gotten the medication showed less agitation overall. About 40 percent of those taking the drug showed moderate to marked improvement, compared to 26 percent among those getting the counseling alone. Family members and other caregivers who were taking care of these patients also showed less stress.

But the drug also had some serious side effects. It caused abnormal changes on EKGs that may be linked to an increased risk of heart disease. Those taking the drug also scored worse on tests of memory and thinking skills compared to those who were getting counseling alone, though the differences were small.

Doctors say that benefits and risks must be carefully weighed when treating agitation in people with Alzheimer’s. “If the agitation is not responding to non-medication treatments and your patient’s agitation isn’t improving, there are no great options,” said Dr. Constantine Lyketsos, the study leader and the director of the Johns Hopkins Memory and Alzheimer’s Treatment Center in Baltimore. “But here’s another medication choice that might be safer than other medications and seems to be just as effective.”

Given that up to a third of people will develop Alzheimer’s by the time they reach age 85, better treatments for the behavioral issues surrounding dementia are needed. Agitation, aggression, irritability, lack of inhibitions and other behavioral issues typically become more common as the disease progresses and can be a tremendous stress for patients and family members.

In addition to drugs, regular activities such as music or art therapy, and pet therapy, may help to ease stress and anxiety, although none of these treatments is a cure. Reducing noise and distractions in the home may also provide some relief. Regular medical and dental care is also essential to rule out pain and other health problems that may be increasing agitation.

By ALZinfo.org, The Alzheimer’s Information Site. Reviewed by William J. Netzer, Ph.D., Fisher Center for Alzheimer’s Research Foundation at The Rockefeller University.

Source: Anton P. Porsteinsson, MD; Lea T. Drye, PhD; Bruce G. Pollock, MD, PhD, et al: “Effect of Citalopram on Agitation in Alzheimer DiseaseThe CitAD Randomized Clinical Trial.” Gary W. Small, MD, “Treating Dementia and Agitation” (editorial). JAMA. 2014; Vol. 311(No. 7): pages 677-678. doi:10.1001/jama.2014.94. February 19, 2014.

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