As dementias progress, whether caused by Alzheimer’s Disease, Vascular Disease, Lewy Body Disease, or some other cause, it is common that people become agitated, like your dad. Agitation is particularly common in the evenings, as you have seen, and when that happens, many people refer to it as “sundowning.” The cause for this phenomenon is not completely clear, but it seems to be a combination of disorientation from the lack of light, endocrine changes that take place as part of our 24-hour circadian rhythm cycle, and fatigue. As the dementia progresses, the agitation often spreads to earlier hours. The agitation is sometimes mild and consists primarily of restlessness, but it can progress to marked aggression. This aggression can be very frightening and dangerous.

Treatment of the agitation that can accompany dementia is challenging. Some things other than medication can be helpful, such as soft music, a favorite television show, or even comforting smells. It is important to not get caught up in arguing with the person with dementia. While it may be reflexive, it is rarely helpful to try to help them understand their beliefs are not accurate. That often just fans the flames. If the person with dementia is depressed, antidepressants can be very helpful. Some people believe mood stabilizers, like Depakote or lamictal can be helpful, though the studies are not very supportive. Sometimes adding a cognitive enhancing medication, drugs that can slow the course of dementia like donepezil, galantamine, razadyne or mementine, can help. It is also important to help your father get a solid night of sleep, and that will likely at least decrease the intensity of the symptoms. I previously answered a question about sleep problems in people with dementia, and I refer you to that if you are interested.

The most common and probably the most effective class of drugs for the treatment of agitation associated with dementia, however, are antipsychotic medications. These drugs are not licensed by the FDA for this purpose and there is a block box warning when they are used to treat someone with dementia. They are thought to increase mortality in this population. On the other hand, they are often very helpful. This is a very tough area, because using them is risky and not using them is risky. There are 7 “atypical antipsychotic” medications available, and they seem to have a somewhat lower risk for serious side effects than the older antipsychotic medications. This group includes ziprasidone, the medication your father is on, as well as olanzapine, risperidone, quetiapine, aripiprazole, papiperidone and clozaril. They each have a unique mechanism of action, so a trial and error period is sometimes necessary. They each require careful monitoring to titrate the dose properly, and sometimes to adjust the time they are given. These are drugs with significant risks, so you want to be sure the doctor you are working with is knowledable about them.

The Lisinopril your dad is taking is for high blood pressure. It is not a treatment for agitation.