Behavior Disorders of Dementia: Recognition and Treatment Arpana Tewari, MD. AAFP Lecture 08/02/06

Psychosis may pose a greater challenge than cognitive decline for patients with dementia and their caregivers

Management of psychosis requires a comprehensive nonpharmacologic and pharmacologic approach, including an accurate assessment of symptoms, awareness of the environment in which they occur

Psychotic features of dementia include hallucinations (usually visual), delusions, and delusional misidentifications

Psychotic Features Hallucinations are false sensory perceptions that are not simply distortions or misinterpretations. Delusions are unshakable beliefs that are out of context with a person's social and cultural background

Psychotic Features Psychotic features in pt’s with Alzheimer’s dementia were in 15 to 75 percent of patients Delusional misidentifications are thought to occur in at least 30 percent of patients with dementia.

Nonpsychotic behaviors Associated with dementia include agitation, wandering, and aggression Interventions include counseling the caregiver about the nonintentional nature of the psychotic features and offering coping strategies.

Approaches for the patient involve 1) Behavior modification; 2) Appropriate use of sensory intervention; environmental safety; 3) Maintenance of routines such as providing meals, exercise, and sleep on a consistent basis

Nonpharmacologic approach First,the behavior problem or symptom must be identified and quantified in terms of frequency and severity. Identification and elimination of precipitating causes are essential. Goals of care should be negotiated with caregivers

Approaches for the caregiver Educate about the disease process Attendance at support group meetings Personal discussion with the physician Resources Coping strategies - remaining calm and using touch, music, toys. Helping the caregiver understand the lack of intentionality of the behaviors is essential.

Behavior approaches Distract patients Asking closed-ended questions Validation therapy Use of reminiscence therapy to recount pleasurable experiences Use of therapeutic activities Reality orientation is not recommended Reassurance to the caregiver

Environment modification Creation of a safe environment Making the environment safe is a work in progress; further modifications will be necessary as the disease progresses

Developing and maintaining routines Consistency Lessens the likelihood of troublesome behaviors

Sensory intervention Music therapy and pet therapy Homelike environment

Pharmacologic Treatment Should be governed by a "start low, go slow" philosophy A monosequential approach is recommended, in which a single agent is titrated until the targeted behavior is reduced, side effects become intolerable, or the maximal dosage is achieved.

Pharmacologic Treatment “Start low, go slow’ Sequential monotherapy Goal of pharmacologic treatment should be reduction, not eradication, Clear identification of target behaviors Careful dosage titration Consideration of alternate or additional agents if the behavior is inadequately controlled.

Atypical antipsychotics 1) Clozapine (Clozaril - Effective in reducing drug-induced psychosis in patients with Parkinson's disease, Requires hematologic monitoring. 2) Olanzapine (Zyprexa)24 - Improvement in agitation and aggression Significant sedation when given at higher dosages, Caution in patients with diabetes.

Atypical antipsychotics 3) Quetiapine (Seroquel) - Antipsychotic of choice in patients with parkinsonian symptoms 4) Risperidone (Risperdal) - Improvement in psychosis and agitation, Warning about "cerebrovascular events" in patients taking this drug

Typical antipsychotics Haloperidol (Haldol) - Variably effective at low dosages Side effects limit use; not recommended except in patients with acute agitation and delirium

Anticonvulsants 1) Carbamazepine (Tegretol) - May reduce aggression Side effects and toxicity limit use 2) Divalproex (Depakote) - Continued improvement in agitation over time; well tolerated Sedation is a common side effect

Acetylcholinesterase inhibitors 1) Donepezil (Aricept) - Improvement in outpatients but not in patients in extended- care facilities 2) Galantamine (Razadyne): formerly Reminyl - Improvement on Neuropsychiatric Inventory Secondary endpoint in populations studied for cognitive loss

Acetylcholinesterase inhibitors 3) Rivastigmine (Exelon) - Less anxiety and psychosis Secondary endpoint in populations studied for cognitive loss

Acetylcholinesterase inhibitors Should not be considered first-line agents in the treatment of psychosis but rather adjunctive treatment Show a delay in time to institutionalization, which may reflect improved behavior, a delay in onset of behavior symptoms, or retention of function.

Antidepressants 1) Citalopram (Celexa) - Reduced agitation 2) Fluoxetine (Prozac) - No data for effect in nondepressed patients 3) Sertraline (Zoloft) - No data for effect in nondepressed patients 4) Trazodone (Desyrel) - Reduced verbal aggression May be effective and could be considered in selected patients

Anxiolytics 1) Buspirone (BuSpar) - No randomized clinical trials support use 2) Lorazepam (Ativan) - No randomized clinical trials support use. Restrict use to patients with acute agitation.

Anxiolytics Chronic benzodiazepine use may worsen the behavior abnormality Has amnestic and disinhibitory effects of these drugs. Use limited to management of acute symptoms that are unresponsive to redirection or other agents. Short-acting BZD with prompt sedative effects may be useful during an episode of acute agitation that fails to respond to reassurance or removal of the precipitant.

Patients with intractable symptoms, hospitalization in a geriatric psychiatry unit, if available, may be necessary. Patients with Lewy body disease, who often present with hallucinations, may be particularly resistant to neuroleptics and may worsen when treated with these agents A reduction in dosage or elimination of agents is appropriate when target symptoms are improved.

Thank You