History of Behavioral Management Treatments

We ve already described in considerable detail the many complications of dementia including depression, psychosis, delirium, and agitation. In general, the evolution of treatments for these symptoms has been straightforward. 

The key has been to avoid using treatments that worsen the disease. In this instance, this means avoiding anticholinergic (acetylcholine-blocking) medications that worsen dementia. As a result, when newer antidepressants such as the SSRIs became available, they quickly replaced the older tricyclic antidepressants because the latter are potent anticholinergics. For the same reason, the low potency anti-psychotics like chlorpromazine (Thorazine) were replaced by the higher potency antipsychotics like haloperidol (Flaldol) and more recently by the atypical antipsychotics. 

However, the evolution of treatment for agitation in dementia deserves further discussion. There have been numerous approaches that have met with varying degrees of success. 

Antipsychotics. Antipsychotic medications are also called major tranquilizers. It is for the tranquilizing effect that they have been used to treat agitation. The earliest antipsychotics, especially thioridazine (Mellaril), proved to be effective in reducing agitation however, this comes at the price of further impairing cognition due to its profound anticholinergic effects. 

The high potency antipsychotic haloperidol (Haldol) provides the same calming effects with minimal anticholinergic effects. Although haloperidol is very effective, dementia patients are quite sensitive to its extrapyramidal effects. These include stiffness, shuffling gait, a mask-like facial appearance, and involuntary movements. To minimize these effects, haloperidol is used in very low doses (0.5-1.0mg) when treating those with dementia. 

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