Alternative formulations, delivery methods, and administration options for psychotropic medications in elderly patients with behavioral and psychological symptoms of dementia

Objective: The purpose of this paper was to review alternative formulations, delivery methods, and administration options for psychotropic medications in elderly patients with behavioral and psychological symptoms of dementia (BPSD).

Methods: A MEDLINE search was conducted initially in December 2008 and was updated in September 2009, including the search terms pharmacologic treatment and dementia, behavioral and psychological symptoms of dementia, alternative psychotropic medication formulations, alternative dosing methods of medication, drug delivery options, antidepressants and dementia, anxiolytics and dementia, antipsychotics and dementia, mood stabilizers and dementia, cognitive enhancers and dementia, medications and enteral feeding tubes, and hiding medication. Studies were limited to English-language articles dated from 1950 to 2009. Additional relevant articles were obtained by reviewing the references in the initial articles. Drug Facts and Comparisons 4.0 Online, Lexi-Comp Online, and Lexi-Drugs Online were used to obtain additional information. Targeted patients were elderly individuals with BPSD who were considered difficult to treat because they were unable to swallow, were refusing medications, or were not able to eat or drink per physician order.

Results: In addition to the standard capsule or tablet given orally, a variety of formulations and delivery methods for psychotropic medications are available. Options include short- and long-acting intramuscular, intravenous, liquid, orally disintegrating, transdermal patch, sublingual, and rectal forms. Additionally, all formulations can be further altered in substance, delivery, or both. For example, tablets may be crushed and capsules opened; this changes their formulation and allows the option of mixing with food or liquids to be taken by mouth or through a tube. Caution must be used, however; in certain cases, alteration of the original form or the intended delivery method is contraindicated. In addition, many alternative administration options are not formally approved for use in the manner in which they are commonly applied and are therefore used with little or no information on tolerability and effectiveness. Ethical and legal issues include patient consent and off-label use.

Conclusions: Overall, few studies have examined the use and efficacy of alternative psychotropic formulations and delivery methods in elderly patients with BPSD, and none have specifically addressed drug-alteration and alternative-administration issues. There is no evidence to compare alternative delivery forms (eg, tablet or capsule) of a given medication in terms of efficacy or tolerability. Still, alternative methods may be the only option for treatment of some patients. Practitioners must be familiar with the range of formulations and delivery options available so that they can optimize their patients' medication regimens. More data are needed on the use of alternative formulations, delivery methods, and administration options and their limitations in this population.