Expert: Mary Gordon - 12/6/2009

Question
Thank you for this website.  My 81 year old mum has been in a board and care for three years. She has some late stage symptoms but can still sit in a chair and they do everything else for her.  Lately she has been screaming out more and this can be disruptive to other residents.

She has been taking 4 mg of respirdal a day.  A new doctor gave her a new added prescription of alprazolam ( 2mg a day).  I noticed yesterday that she was like a zombie and twitching a lot.  Her eyes were closed.

I realize that this is probably a medical question, but could this be the onset of seizures that you mentioned in reponse to another viewer or the medication?

Thanks in advance............

Answer
Hi Molly,

If I were a betting woman, I'd put money on the idea that what you are seeing is likely the direct result of the drugs she is on, and not the disease itself.  Alprazolam (also known as Xanax) is a benzodiazepine  - these drugs (which include ativan and valium) are generally something to avoid in people with h Alzheimer's disease or any other dementia because they can worsen confusion and increase the risk of falls. And, as in all people, benzodiazepines are addictive. Elderly patients may be more sensitive to the effects of alprazolam including oversedation - which you are seeing, and general purpose floppiness and lack of coordination (called ataxia). Because elderly people often have decreased liver and kidney function, they can be very slow to process this drug out of their systems.

The dose (2 mg/day) is actually very high for her situation - and the sleepiness you are seeing is a direct consequence.  Usually, an initial dose will be very low for an elderly person - the aim is to reduce agitation and anxiety with the lowest possible dose. It is not ethical or appropriate to "zombify" her, so the doctor needs to either cut the dose back and see if a much lower dose relieves her agitation, or find another medication. A usual first dose should be more like 0.5 mg daily. It is important not to stop taking a benzodiazepine abruptly because the withdrawal symptoms can be severe and life-threatening. It must be tapered off slowly.

That said, among benzodiazepines, Xanax is typically preferred because it has a shorter half-life than others. This means the effects of the drug wear off faster. Occasional use of Xanax can be helpful in situations where an anti-anxiety medication may be useful, such as before a medical procedure or before a flight.   

I would discuss the reasons for the current dosage and choice of drug with your mother’s doctor. An appropriate anti-depressant will often  reduce anxiety. Most of the so-called SSRI anti-depressants (Prozac/fluoxetine, Celexa/citalopram, Lexapro/escitalopram, Paxil/paroxetine, Zoloft/sertraline) are also separately approved for anxiety. They are not addictive and are safer over for long-term use. I'd give the citalopram a go if the doctor is willing to bring her off the xanax entirely. I'd also talk to him about the respiridal and see if its use is still called for. It might be time to wean her off both, and see what happens. The respiridal alone will make her excessively sleepy and it can cause muscle spasms - and again, she is on quite a high dose for a frail elderly person (4 mg/day). A more typical dose for a person with behavioral issues at her stage would be about 1/4 of what she is currently on - so this is also worth a serious review - whether she should be on it at all, and if the dose needs to be cut back.

You know your mother better than anyone. If what you are seeing doesn't seem right, don't be intimidated by doctors. The point of any medication is to improve her quality of life - to make her happier, calmer and more comfortable. Making her sleep all the time and be floppy is NOT what the point is, even if it makes the staff happy not to hear her yelling. In a case like this, the medications are essentially being used as a "chemical restraints", and it is not acceptable.  

You don't have anything to lose by cutting back gradually to see if she improves.

Mary