Review

Anticonvulsants in the treatment of aggression in the demented elderly: an update

Benedikt Amann¹, Johannes Pantel², Heinz Grunze³, Eduard Vieta⁴, Francesc Colom⁴, Ana Gonzalez-Pinto⁵, Dieter Naber⁶ and Harald Hampel^7,8

¹  Benito Menni, CASM, Research Unit, CIBERSAM, St Boi de Llobregat, Barcelona, Spain

²  Department of Psychiatry, University of Frankfurt, Germany

³  Institute of Neuroscience, University of Newcastle upon Tyne, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, UK

⁴  Bipolar Disorders Program, Clinical Institute of Neuroscience, CIBERSAM, University Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain

⁵  Department of Psychiatry, Santiago Apóstol Hospital, CIBERSAM, Vitoria, Spain

⁶  Psychiatric Department, University of Hamburg Eppendorf, Germany

⁷  Alzheimer Memorial Center, Department of Psychiatry, Ludwig-Maximilian University, Nussbaumstrasse 7, 80336 Munich, Germany

⁸  Discipline of Psychiatry, School of Medicine and Trinity College Institute of Neuroscience (TCIN), Trinity College, University of Dublin, Trinity Center for Health Sciences, Tallaght, Dublin 24, Ireland

Clinical Practice and Epidemiology in Mental Health 2009, 5:14doi:10.1186/1745-0179-5-14

Published:	16 June 2009

Abstract

Introduction

Complex psychopathological and behavioral symptoms, such as delusions and aggression against care providers, are often the primary cause of acute hospital admissions of elderly patients to emergency units and psychiatric departments. This issue resembles an interdisciplinary clinically highly relevant diagnostic and therapeutic challenge across many medical subjects and general practice. At least 50% of the dramatically growing number of patients with dementia exerts aggressive and agitated symptoms during the course of clinical progression, particularly at moderate clinical severity.

Methods

Commonly used rating scales for agitation and aggression are reviewed and discussed. Furthermore, we focus in this article on benefits and limitations of all available data of anticonvulsants published in this specific indication, such as valproate, carbamazepine, oxcarbazepine, lamotrigine, gabapentin and topiramate.

Results

To date, most positive and robust data are available for carbamazepine, however, pharmacokinetic interactions with secondary enzyme induction limit its use. Controlled data of valproate do not seem to support the use in this population. For oxcarbazepine only one controlled but negative trial is available. Positive small series and case reports have been reported for lamotrigine, gabapentin and topiramate.

Conclusion

So far, data of anticonvulsants in demented patients with behavioral disturbances are not convincing. Controlled clinical trials using specific, valid and psychometrically sound instruments of newer anticonvulsants with a better tolerability profile are mandatory to verify whether they can contribute as treatment option in this indication.