When my mother was first diagnosed with Alzheimer’s, she was still the easygoing, affable woman who had raised me. But over the next couple of years, her personality morphed into something altogether unrecognizable. She became vindictive, suspicious, reacted violently when frustrated (a frequent occurrence), and suffered from hallucinations. Consequently, her doctor prescribed psychotropic medications to lift her mood, calm her anxiety, and make her medically compliant. While she behaved less violently on the psychotropics, her speech became slurred, she was apathetic, and basically moved through each day like a zombie. In some respects, my mother was safer, but what I didn’t realize was that psychotropic medications greatly increase the risks of movement disorders, strokes, and sudden cardiac death. That meant that my mom’s calmer demeanor was potentially traded-off for shortening her life.
While I had some formal medical training in college, I didn’t learn about psychotropic medications. And my predicament is not uncommon; family members are often unaware of the serious risks posed by psychotropics, and 83% of seniors with dementia are cared for by an unpaid family member. Very few of these family members ever expected to become caregivers, let alone undertake the formal education and training to become experts. Rather, we put our trust doctors, nurse practitioners, and other medical professionals to help us manage our loved ones during these worst of times.
Like my mother, 97% of seniors with dementia will develop behavioral and psychological symptoms of dementia (BPSD). BPSD symptoms include apathy, depression, loneliness, anxiety, frustration, wandering, hallucinations, violent anger, and refusal of care. To help manage these symptoms and to help keep patients safe, doctors frequently prescribe “PRN” psychotropic medications. PRN is an acronym for the Latin phrase pro re nata, which loosely translates to “as needed.” (Aspirin, Tylenol, and antihistamines like Benadryl are other examples of ‘as needed’ medications.) Psychotropics are not intended to be taken in an ongoing, permanent manner, but despite being prescribed as “PRN,” many dementia patients are administered psychotropic medications regularly on a quasi-permanent basis.
The dangers of these medications are abundantly clear, especially for antipsychotics. Multiple scientific studies published in medical journals have demonstrated the increased risks, going so far as to question whether the use of psychotropics is at odds with the medical tenet “First, do no harm.” The FDA was so concerned about psychotropics, that in 2005 they mandated black box warnings—the most severe warning the FDA will issue while still allowing a medication to remain on the market—on many of these drugs. And yet, these medications are still prescribed with high frequency.
In 2017, the Centers for Medicare and Medicaid Services (CMS) finally issued an F-Tag alert (F-758) mandating stricter controls on the use of psychotropics in long term care facilities:
“Facilities must ensure that…residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions… in an effort to discontinue these drugs.”
In addition to gradual dose reductions, CMS now requires “non-pharmacological interventions” to “promote and maintain the resident’s highest practicable mental, physical and psychosocial well-being.”
The following table contains a list of psychotropic medications commonly prescribed for seniors with dementia:
|Abilify (aripiprazole)||Aristada (aripiprazole lauroxil)||Clozaril (clozapine)||Hydergine (ergoloid mesylates)||Fanapt (iloperidone)||Fazaclo (clozapine)||Geodon (ziprasidone)|
|Haldol (haloperidol)||Invega (paliperidone)||Latuda (lurasidone)||Loxitane (loxipine)||Mellaril (Thioridazine)||Moban (molidone)||Navane (thiothixene)|
|Nupazid (pimavanserin)||Prolixin (fluphenazine)||Reagila (cariprazine)||Rexulti (brexipiprazole)||Risperdal (risperidone)||Saphris (asenapine)||Serentil (mesoridazine)|
|Seroquel (quetiapine)||Stelazine (trifluoperazine)||Thorazine (chlorpromazine)||Trilafon (perphenazine)||Versacloz (clozapine)||Vraylar (cariprazine)||Zyprexa (olanzapine)|
|Celexa (citalopram)||Cipralex (escitalopram)||Cymbalta (duloxetine)||Desyrel (trazodone)||Effexor (venlafaxine)||Lexapro (escitalopram)|
|Luvox (fluvoxamine)||Paxil (paroxetine)||Prozac (fluoxetine)||Serafem (fluoxetine)||Wellbutrin (bupropion)||Zoloft (sertraline)|
|Ativan (lorazepam)||BuSpar (buspirone)||Inderal (propranolol)||Klonopin (clonazepam)||Lubrium (chlordiazepoxide)||Serax (oxazepam)|
|Tenormin (atenolol)||Tranxene (clorazepate)||Valium (diazepam)||Xanax (alprazolam)|
It was a constant battle with my mother’s doctors, nurse practitioners and other medical professionals to reduce my mother’s psychotropic medication use. By the end her life, my mother spent more time in these “chemical restraints” than out of them. While I don’t hold malice towards these medical professionals, they clearly have not been trained to investigate non-pharmacological behavioral interventions. Further, a 15-minute consult every month or two cannot possibly give them the insight necessary to understand each patient’s unique challenges.
Family members need to talk to their loved ones’ medical professionals about the medications they are prescribing, and demand their practice include non-pharmacological interventions.
Tombot’s robotic companions are part of a behavioral intervention strategy to reduce or eliminate the use of psychotropic medications.
 Alzheimer’s Association, Alzheimer’s Disease Facts and Figures, 2018
 Steinberg et al, Int J Geriatric Psychiatry, 2008
 Maust et al, JAMA Psychiatry, May 2015
 F-Tag 758, CMS State Operations Manual, Appendix PP – Rev 173, November 22, 2017