Buspirone for Stereotypic Movements in Elderly With Cognitive Impairment

R epetitive or stereotypic behaviors are common in demented elderly. These behaviors may include simple motor movements, such as patting, rubbing, scratching, picking, placing nonfood items in the mouth, or verbalizations that can include counting or repetitive sounds. Although these behaviors may seem minor when compared with aggressive or combative behaviors, they may bring harm to the patient by causing skin breakdown and subsequent infection or causing the patient to swallow potentially harmful nonfood items. In addition, these behaviors may irritate or agitate others in a facility setting (e.g., constant patting on a table causing unending noise) or become overwhelming to caregivers. 1 – 3

A study of 141 patients with dementia revealed that 79 had repetitive behaviors, which typically developed in early stages of dementia. 2 Some research has noted an increased prevalence of repetitive behaviors in dementias of frontal lobe type when compared to Alzheimer’s disease. 4 – 8 Other studies have suggested that combined damage to the frontal lobe, caudate nucleus, and globus pallidus may contribute to these behavioral disorders. 4

Currently, very little is known about treatment for stereotypic behaviors in dementia. A case report of three patients with dementia, two with Alzheimer’s disease and one with vascular dementia, showed improvement during treatment with fluvoxamine with doses up to 150 mg per day. 9 In this article, we review six cases of dementia with repetitive behaviors that responded to buspirone, a 5-HT1A antagonist medication.

CASE 1

A 74-year-old male with Alzheimer’s dementia and depressed mood developed the behavior of skin picking that was unassociated with any other behavioral or medication change. The skin picking was isolated to his left arm and resulted in skin breakdown and infection. The patient denied any complaints of itching or other symptoms to explain his picking except in one interview where he gave the explanation that he had gun pellets under his arm that needed to be removed. However, no other psychosis was noted. The patient’s mood was also stable without depressive symptoms. He was started on buspirone 5 mg b.i.d., and after 1 month, the behavior decreased only slightly. His buspirone dose was then increased to 7.5 mg b.i.d. This led to significant improvement in his skin picking, with healing of the skin. No side effects were noted.

CASE 2

A 71-year-old woman with a history of profound mental retardation developed a stereotypic movement disorder manifested by pulling and eating her hair (trichophagia). She was nonverbal and could not answer questions about her behavior, and there were no apparent mood symptoms. Due to concerns of possible anxiety as a component of the behavior, she was started on buspirone 5 mg twice daily. This resulted in an observable decrease in the hair-pulling/hair-eating behavior. The dose of buspirone was increased to 10 mg twice a day, and the behavior stopped. Since the symptoms did not recur in the following 3 months, a taper in the buspirone was attempted, but the hair pulling/eating behaviors recurred. The dose of buspirone was then returned to the previous dose of 10 mg twice daily, with resolution of the behavior. No side effects were noted.

CASE 3

A 79-year-old woman with a diagnosis of vascular dementia and bipolar disorder developed repeated scratching behavior with resultant skin breakdown on the face, chest, and legs. The patient could not explain a reason for the scratching, denying any symptoms of itching or discomfort, and there was no psychosis noted. She was on venlafaxine, lithium, and quetiapine for bipolar disorder, which was in full remission, and donepezil for dementia (moderate range). The patient was started on buspirone 5 mg twice daily, and the dose was titrated up to 10 mg twice daily. The skin scratching improved on the higher dose of buspirone, although it was not completely eliminated. An additional midday dose of 5 mg of buspirone resulted in full improvement. No side effects were noted.

CASE 4

An 84-year-old married white woman with a diagnosis of dementia due to alcoholism began picking and scratching at her frontal scalp, causing a localized loss of hair and bleeding of the scalp. Numerous creams and treatments, including oral antihistamines, did nothing to prevent the scratching. She could not explain why she was scratching and, in fact, denied itchiness in the area. No affective symptoms were noted. A trial of buspirone 5 mg b.i.d. did not alleviate symptoms, but an increase to 10 mg b.i.d. resulted in a dramatic decrease in her scratching and picking behaviors, with healing of the skin and hair regrowth. No side effects were reported.

CASE 5

An 83-year-old white woman diagnosed with senile dementia of the Alzheimer’s disease type—severe—began to scratch her arms and legs. Due to severity of dementia, and essential mutism, she could offer no reason for the behavior. Treatments from a dermatologist did not change her scratching behaviors, and there were no apparent mood symptoms. Treatment with buspirone 5 mg b.i.d. resulted in a marked reduction in scratching, which resulted in healing of the skin. No side effects were noted.

CASE 6

An 83-year-old white woman with vascular dementia developed skin breakdown on her legs and abdomen, with persistent scratching. She also had a history of depression, although in full remission at the time of this study, taking venlafaxine XR 75 mg per day. She denied itching and could not explain her scratching behavior. There were no depressive or anxiety symptoms reported. Buspirone 2.5 mg b.i.d. resulted in improvement of the scratching behaviors and healing of her skin. No side effects were noted.

DISCUSSION

The case reports presented in this article demonstrate that buspirone may be an effective and safe treatment for patients with dementia who demonstrate repetitive and stereotypic behavior disorders. Because patients with moderate to severe dementia are unable to describe their mental state in detail, if at all, it is difficult to know whether the buspirone was relieving the anxiety or another symptom associated with the repetitive behavior. Although no patient was able to describe anxiety, observation of the behavior suggested anxiety in some patients, so it is hypothesized that the buspirone decreased anxiety and thus the behavior. It is possible that, as a 5-HT1A antagonist, buspirone works through a serotonergic mechanism to decrease these behaviors. Future trials of buspirone are needed to further explore the usefulness of this medication in repetitive and stereotypic behaviors in dementia.