12 - BPSD: Pharmacologic Approach

In Part 2 of our series on Behavioral and Psychological Symptoms of Dementia (BPSD), Eric Gordon, PA-C, and Dr. Steve Arze dive into one of the toughest clinical challenges in geriatrics and post-acute care: when and how to use medications to treat behavioral symptoms in dementia. Building on last episode’s discussion of non-pharmacologic strategies, this conversation tackles the realities of prescribing in complex older adults, where polypharmacy, overlapping symptom presentations, and regulatory pressures converge. In this episode, you’ll learn: Why medications are not first-line treatment and what must be ruled out before reaching for a prescription. How serotonin toxicity is often missed, how it mimics BPSD, and why stacking serotonergic agents can fuel agitation, sleep disruptions, tremors, and worsening confusion. Which medication classes have evidence and which don’t, including: SSRIs Trazodone Anticonvulsants (valproate, gabapentin) Benzodiazepines Melatonin Cholinesterase inhibitors Why valproic acid and gabapentin are widely used but poorly supported for BPSD. Why benzodiazepines should generally be short-term “bridge” therapy, not long-term solutions. The surprising truth about ABH gel (spoiler: the massage may work better than the medication). Key takeaways from Fast Facts #499 from the Palliative Care Network of Wisconsin. How cholinesterase inhibitors may still help with behavior even in advanced dementia—and when to consider a trial. The importance of continual reassessment to avoid “set it and forget it” prescribing. This episode is packed with practical pearls for clinicians practicing in SNFs, ALFs, home-based care, hospice, and geriatrics—helping you identify what truly works, avoid common pitfalls, and manage behaviors safely and effectively.