I am very concerned that the approach being proposed will have the unintended consequence of reducing the quality of life of the elderly patient with dementia who is admitted to a psychiatric unit with behavioral dyscontrol . As we are routinely willing to use pain killers (e.g. opiates) that we recognize have the unintended consequences of increasing morbidity and mortality in all patients, but particularly the elderly why do we not consider quality of life in these patients as well.

Elderly patients coming into psychiatric hospitals from either home or ALF or nursing facilities are individuals who cannot be cared for in a way that fosters their quality of life. Currently, there are no medications that have been FDA approved for treatment of dementia with behavioral dyscontrol. Clinicians should not be discouraged from using the broad spectrum of medications available to them to determine whether on an individual basis a particular medication is helpful.

While we would all love to have behavioral interventions that would serve this purpose there is no convincing data that treating behavioral dyscontrol with non pharmacological means is effective in the vast majority of patients even under the ideal conditions of a research study never mind in the typical clinical setting. These patients are typically suffering as demonstrated by their obvious fearfulness and agitation. In many instances they are unable to give voice to their emotions either because of cognitive impairments, but also because of a disconnection between their emotions and mental ideation.

The unintended consequences of restricting use of one class of medications will lead to the use of other medications that also likely to increase morbidity and mortality due to dyscontrol, balance problems, greater cognitive impairment and falls, e.g., high doses of benzodiazepines, antidepressants, antiepileptic drugs.

One final comment. Should you continue along this path which I don't believe is a good idea I would suggest that you, at least, allow a category of reasonable use of antipsychotics for augmentation of antidepressants in elderly patients suffering from major depressive disorder, particularly those in anxious distress.