Expert: Mary Gordon - 10/25/2008

Question
MY FATHER IS 74 YEARS OLD. HE HAS ALTZHEIMERS FOR 6 YEARS.  PRESENTLY IN PHASE 7.  IS THERE ANY MEDICATION FOR SLEEPLESS AND RESTLESSNESS.  KEEPS PACING AND DOING SILLY THINGS AND FALLING AS A RESULT, HURTING HIMSELF.  HE IS USING AROSEP AND AROPAC. NEW DRUG THAT HAS BEEN PRESCRIBED YESTERDAY NAMELY RISPEDRAL.

Answer
Hi Marianne, below my signature I've pasted the last two stages. If he's this mobile and agitated, he's more likely still in Stage 6 than 7, which is the final stage. By 7, they usually can't do much at all (i.e. they are usually no longer able to walk).

Aricept (donpezil) is a drug that helps slow down the progress of the dementia. It is a cholineserase inhibitor. It doesn't always do much for the agitation and sleeplessness. If I were you, I'd ask about adding namenda (memantine) in combination with the aricept or with Reminyl (also known as Razadyne/galantamine). Not sure what "aropac" is.

The aricept should be taken in the morning, because it can cause sleeplessness. To improve his sleep, make sure you keep him awake during the day as much as possible, to ensure he is tired at night, and try and make sure he gets some exercise (maybe get someone to take him for walks holding his arm). Don't let him have coffee or tea after noon (or give him decaf). Set a daily routine (getting up and going to bed at regular hours, predictable times for meals etc.), so he will be cued for sleep in the evening. Leave some night lights on in the bedroom, hall and bathroom so he doesn't get disoriented. I'd ask the doctor about trying meds given at bedtime in small dose for sleep such as Trazadone.  

Respiridol is an antipsychotic, and is often tried for the anxiety and agitation that many people experience in later AD. Give it some time. No single drug is going to work for everyone, but this one works reasonably often to make the person less aggressive, and anxious. Its worth a shot.

The down side is that it can increase risk of stroke. However, everything comes with a price tag - everything is a trade off, so nothing is perfect. Give it a try for at least a month or two, and see what happens. Keep an eye on him for side effects, and let the doctor try a few different doses to see if helps. I know how difficult it is for a caregiver to look after someone who won't sleep, and is very upset and keyed up, or is endlessly pacing or fidgeting.

Anti-depressants (specifically the selective serotonin reuptake inhibitors or SSRIs), rather than anti-anxiety medication (such as the benzodiazepines), are the preferred medication for most anxiety disorders. He could try Zoloft or Prozac, or some of the others, if the respiridol doesn't pan out.

No matter what meds you try, be prepared always that nothing works the same for everyone. You might have to experiment with a few to see what helps. You know him best. Sometimes drugs have the totally opposite effect on people with Alzheimer's than was intended, so you really have to watch carefully for how well something is working, and if it isn't or its causing lousy side effects, take him off it after discussing alternatives with the doctor.

His falling is in part from his brain damage. He is losing control of his muscles, and his sense of balance. It is very dangerous to him - he could seriously injure himself. The end of walking came early for my mother in law because of a fall that broke her hip. Although it was repaired, she couldn't cooperate with the therapy, so we were never able to get her back on her feet again.

Because his ability to perceive is also damaged, he will have trouble going from one surface to another (i.e. a smooth floor to a carpet). He will have trouble knowing what to do. They often don't lift their foot high enough and will catch their foot on the rug and fall. Really thick carpets will do this. Make sure you keep the house uncluttered. You might want to make sure there are no cords, small rugs, small furniture etc. that he will trip over.

Hope this helps a bit. Its a tough problem to deal with.

Mary G.


Level 6
Severe cognitive decline (Middle Dementia or Moderately Severe AD). May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the season, etc. May have difficulty counting from 10, both backward and sometimes forward. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to orient in familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. Personality and emotional changes occur. These are quite variable and include
(a) delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror;
(b) obsessive symptoms, e.g., person may
continually repeat simple cleaning activities;
(c) anxiety symptoms, agitation, and even previously nonexistent violent behavior may occur;
(d) cognitive abulla, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of
action.

6a - Requires Assistance dressing
6b - Requires Assistance bathing properly
6c - Requires Assistance with mechanics of toileting
6d - Urinary incontinence
6e - Fecal incontinence

Level 7
Very severe cognitive decline (Late Dementia or Severe AD). All verbal abilities are lost. Frequently there is no speech at all - only grunting. Incontinent of urine, requires assistance toileting and feeding. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. The brain appears to no longer be able to tell the body what to do. Generalized and cortical neurologic signs and symptoms are frequently
present.

7a - Speech ability limited to about a half-dozen intelligible words
7b - Intelligible vocabulary limited to a single word
7c - Ambulatory ability lost
7d - Ability to sit up lost
7e - Ability to smile lost
7f - Ability to hold up head lost