Behavioral and Psychiatric Symptoms Accompanying Dementia

Key Points

• It is necessary to understand the behavior from the patient's point of view to develop a treatment plan.

• Treating distressing symptoms, such as pain or constipation, may resolve problematic behaviors.

• As the patient's dementia progresses, behaviors are likely to change.

Behavioral and psychiatric symptoms occur frequently in dementia patients. Behavioral symptoms usually increase the suffering of the patient and are very distressing for both family and professional caregivers. Common problem behaviors include wandering, repetitive movements, verbal or physical aggression, resistiveness, pestering, hoarding, inappropriate sexual behavior, and sleep disturbances.

Many patients display psychotic symptoms at some point in the course of their dementia. Simple delusions, hallucinations, and paranoia may occur because of misperceptions of the environment. True psychotic delusions and hallucinations, which are usually visual rather than auditory, may also occur. Any of these symptoms can cause considerable distress, generating requests for the physician to prescribe antipsychotic or sedating medication with the intent to suppress the problematic behavior.

The genesis of psychotic symptoms in the degenerating brain of the dementia patient probably differs from the psychotic symptoms associated with schizophrenia or other psychotic mental illness, and therefore antipsychotics are only occasionally effective. The FDA has not approved antipsychotic drugs for use in dementia patients. A clinical review concluded "pharmacological therapies are not particularly effective for the management of neuropsychiatric symptoms of dementia" (Sink et al., 2005). The safety of these agents in the frail elderly population is also a concern. In 2008 the FDA notified physicians that "both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia-related psychosis. "

For all these reasons, nonpharmacologic interventions are preferred for the management of behavioral and psychiatric symptoms. This requires analysis of the problematic behavior, seeking to understand the behavior from the patient's perspective. Attention to precipitating events and consequences of the behavior can lead to a behavioral modification plan. The dementia patient's profound memory loss may be the basis for some behavioral symptoms. Repeated questioning may reflect extreme short-term memory loss. Paranoia-like verbalizations that people are stealing the patient's possessions occur when the dementia patient cannot remember where possessions are kept. Box 48-10 provides a guideline to assist the evaluation and management of behavioral problems.

Depression is typically seen in dementia patients and is often the cause of irritability, apathy, anorexia, insomnia, or other symptoms that can drive problem behaviors. Successful treatment of the depression is marked by resolution of the problematic behaviors. Unmet physical needs (e.g., pain, constipation) should also be sought as a possible underlying stimulus for problem behavior.

KEY TREATMENT

Typical and atypical antipsychotics show some benefit in dementia patients, particularly in controlling aggression and psychosis, but also carry significant risk, including increased mortality (Sink et al., 2005). (SOR: B).

If antipsychotics are used, low doses and short duration of therapy are recommended (SOR: C).

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