From the Guidelines
For a dementia patient already on maximum doses of risperidone (Risperdal) and duloxetine (Cymbalta) who continues to experience crying and labile mood, I would recommend adding citalopram (Celexa) at 10mg daily, increased to 20mg after 1-2 weeks if needed, as it has evidence for emotional lability in dementia 1. This approach is supported by the guidelines for managing Alzheimer's disease, which suggest that selective serotonin reuptake inhibitors, such as citalopram, are effective and have few side effects for the treatment of depression in patients with dementia 1. Before adding medication, it is essential to ensure the patient has had a thorough evaluation for physical causes of distress such as pain, constipation, or urinary tract infection. Non-pharmacological approaches should be implemented concurrently, including:
- Consistent daily routines
- Music therapy
- Caregiver education on redirection techniques These interventions may help stabilize mood by regulating neurotransmitters and neural circuits involved in emotional regulation, which are often disrupted in dementia. Regular monitoring for side effects, particularly sedation, falls risk, and cognitive changes, is essential with any medication adjustment. It is also important to consider the potential benefits and harms of adding a new medication, as antipsychotics, such as risperidone, are associated with clinically significant adverse effects, including mortality 1. Therefore, the decision to add a new medication should be made on a case-by-case basis, taking into account the individual patient's circumstances and clinical presentation.
From the Research
Adjunct Therapy for Dementia Patients
Given the patient is already on risperdal and cymbalta, which are maxed out for crying and labile mood, an adjunct therapy could be considered to manage behavioral and psychological symptoms of dementia (BPSD).
- Mood Stabilizers: According to 2, carbamazepine has the most robust evidence of efficacy on BPSD, particularly aggression and hostility, among mood stabilizers.
- Anticonvulsants: A literature review 3 found that anticonvulsant mood stabilizers (carbamazepine, valproic acid, gabapentin, lamotrigine, topiramate) cannot be recommended for routine clinical use in the treatment of BPSD due to limited evidence and frequent adverse effects.
- Risperidone: Studies 4, 5, 6 have shown that risperidone is effective in managing agitation, aggression, and psychosis in dementia patients, with a relatively benign adverse-effect profile. However, safety concerns have emerged due to increased risk for cerebrovascular adverse events and death following its use in the elderly population.
Considerations for Adjunct Therapy
When considering an adjunct therapy, it is essential to weigh the potential benefits and risks, particularly in elderly patients with dementia.
- Carbamazepine: May be considered as an adjunct therapy due to its efficacy in managing BPSD, particularly aggression and hostility 2.
- Monitoring: Close monitoring of the patient's response to adjunct therapy and potential adverse effects is crucial.