Recent studies suggest medications for treating the behavioral aspects of dementia are ineffective.¹

There are no medications specifically targeting the following symptoms of dementia: wandering, sexual inappropriateness, yelling, repetitive questioning, weight loss and hoarding.

Yet, nursing home staff continues to request consults for medication evaluations for patients exhibiting these behaviors at high rates. What medications are being tried, and what can be implemented in place of medication?

Wandering

• Symptoms: Wandering is a major cause of concern in nursing homes. Wandering into other residents' rooms can lead to conflicts. Patients wander to search for something, get away from noisy environments and/or to relive the past (i.e., going to work).² Wandering may lead to elopement (leaving the premises), which puts the resident at further risk.

• Medications: Medications prescribed to prevent wandering, or elopement, most often include benzodiazepines and trazodone. These medications sedate the patient but do not prevent wandering. This sedative effect now makes the wandering patient less steady and more prone to falls, postural hypotension and frustration leading to agitation.

Antipsychotics also are not effective for this reason. They also are not allowed under the Omnibus Budget Reconciliation Act because they are viewed as a chemical restraint.³ Moreover, when antipsychotics are used they may cause akathisia, an inner restlessness that may actually make the patient wander more. Sometimes antipsychotics, benzodiazepines and trazodone will prevent wandering by oversedation, making the patient more prone to pneumonia, de-conditioning and at risk for falls.

• Alternative Interventions: Although it is impossible to eliminate all wandering, changes in the environment can be helpful so it can be done more safely. Eliminate tripping hazards, use alarms to alert staff, use signs (familiar to long-term memory, such as stop signs), camouflage doors and exits, use good lighting, and provide frequent toileting and pain assessment.

Placing a black floor mat by the door may prevent wandering as well. Since many patients with dementia have impaired depth perception, "they may read the mat as a hole, and often hesitate to step on it."⁴ Floral or busy patterns on rugs should be avoided as they may confuse the patient.⁴

Two important considerations for providing a safe environment for wanderers are the physical space and staff action. Successful dementia units have a circular track for wandering. Staff must be educated to assist wanderers and be mindful of it.

 Sexual Inappropriateness

• Symptoms: Sexual inappropriateness can be in the form of suggestive comments, public masturbation or touching of staff during close-up care. This is often viewed as either a function of an increased libido or impulse control. The majority of these patients are male, but female patients can exhibit these behaviors.

• Medications: To decrease libido, selective serotonin reuptake inhibiting drugs (SSRIs) are often prescribed. To aid impulsivity, mood stabilizers such as valproic acid, lamotrigine or oxcarbazepine may be tried. There is little evidence medroxyprogesterone, a common form of birth control that contains a synthetic version of the female hormone progesterone, aids these patients; although it is used to decrease sex drive. For the most part, these drugs are ineffective and can cause multiple side effects.⁵

• Alternative Interventions: Many nursing homes do background checks to make sure the patient does not have a history of sexual deviancy. If they do, these patients should be closely monitored. Most of the patients who are sexually inappropriate do not have this history. The best approach to take when patients are inappropriate is to inform them the behavior is not appropriate, excuse yourself from the room, and inform them you will be glad to resume care when they are in control and respectful. Using two or more staff members when available and having a male presence can be helpful.

Also, enlist families in helping with this behavior. I have seen male patients with dementia who had exhibited inappropriate sexual behavior improve when their wives addressed it with them.