Calm agitation in Alzheimer's

For the study, reported in the Feb. 19 issue of the Journal of the American Medical Association, Constantine Lyketsos, M.D., M.H.S., and his colleagues recruited 186 patients with Alzheimer’s who showed a collection of symptoms including emotional distress, excessive movement, aggression, disruptive irritability and disinhibition. 

None experienced adequate symptom relief with non-medical therapies, and some experienced failed treatment with antipsychotic drugs. Though antipsychotics are often used as first-line medications for Alzheimer’s-related agitation, they significantly increase the risk of strokes, heart attacks and death, Lyketsos says.

At the start of the study, patients also underwent tests to define the extent of their agitation, memory and other cognitive skills, and their caregivers’ stress levels, a factor strongly linked to the well-being of those with Alzheimer’s. 

The patients were then separated into two groups. For the next nine weeks, about half took increasing doses of citalopram that peaked at 30 milligrams per day, and the rest took an identical-looking placebo.

At the end of the study period, the same set of tests was given, along with electrocardiograms. The study drug is linked to adverse effects on heart function, including irregular heartbeat, a harbinger of a heart attack.
Results showed that patients on the drug had significant relief from their agitation symptoms, Lyketsos says. In one measure of agitation, about 40 percent of patients who took citalopram had “considerable relief,” compared to 26 percent of patients who took the placebo. The caregivers for these patients reported less stress.

However, patients on the drug were also more likely to have slightly decreased cognitive function. “It was not huge, but measureable,” says Lyketsos, director of the Johns Hopkins Memory and Alzheimer’s Treatment Center and director of the Department of Psychiatry at Johns Hopkins Bayview Medical Center. “That introduces a tradeoff.”
More concerning, he adds, is that patients on citalopram had longer QTc intervals, a measure of abnormal heart function that increases the risk of heart attacks. However, Lyketsos says, antipsychotic medications also used to treat agitation increase heart attack risk as well, perhaps even more substantially.
Lyketsos and his colleagues hope to test if a lower dose of citalopram might be just as effective in treating Alzheimer’s-related agitation with less risk for cognition and heart function. In the meantime, he says, the drug offers an alternative to antipsychotics.
“If the agitation is not responding to non-medication treatments and your patient’s agitation isn’t improving, there are no great options,” Lyketsos says. “But here’s another medication choice that might be safer than other medications and seems to be just as effective