In my work assessing brain damage and dementia in adults, carbamazepine (Tegretol) in low doses (50 -100 mg per day) has often been effective. Particularly in cases where possible fronto-limbic lesions have caused unprovoked aggression, confusion, shouting or wandering. Neuroleptics, on the other hand, have often paradoxically reinforced the unwanted behavior. Have you considered or tried this treatment? If so, what is your experience of the effect?
I am not a big fan of carbamazepine (CBZ), since it can markedly diminish blood levels of other psychotropics (such as antipsychotics and some antidepressants) and is often not well-tolerated by patients. Since I’ve found valproate (Depakote) easier to use and better-tolerated, I tend to prefer it to CBZ in the kind of patient you are describing. Recently, some anecdotal data suggest that gabapentin may also be useful in agitated, demented patients (see Regan and Gordon, Journal of Clinical Psychopharmacology February 1997).
Having said all this, I do think there are good data to support your practice in aggressive demented patients, and perhaps also in younger patients with fronto-limbic lesions (see, for example, Tariot et al, Journal of the American Geriatric Society 1994;42:1160-1166 and McAllister, Journal of Clinical Psychiatry 1985;46:393-94). I agree with you that neuroleptics in non-psychotic aggressive/agitated patients-can often be counter-productive, particularly when they induce akathisia or other extrapyramidal effects. On the other hand, some preliminary data suggest that low doses of risperidone (0.5-1.5 mg/day) can help agitated demented patients (Herrmann et al, Journal of Neuropsychiatry Spring 1998).