• Videotapes of family members

• Audio tapes of the voices of caregivers

• Walking and light exercise

• Sensory stimulation and relaxation

The atypical antipsychotics are the preferred agents for the treatment of psychosis (hallucinations, delusions, and suspiciousness) and the disruptive behaviors (agitation and aggression) of AD. Double-blind, controlled trials support the efficacy of risperidone and olanzapine in reducing the rate of psychosis and agitation.46-48 Risperidone should be initiated at 0.25 mg/day and titrated in 0.25 to 0.5 mg/day increments to 1 mg/day, with a maximum dose of 2 mg/day.46,47,49 Olanzapine has been studied with modest results at doses of 5 to 10 mg/day, and 15 mg/day has not been

shown to be any better than placebo.

In April 2005, the FDA issued a statement requesting black-box warnings on all atypical antipsychotics stating that elderly people with dementia-related psychosis treated with an atypical antipsychotic are at an increased risk of death compared to those treated with placebo. Of a total of 17 placebo-controlled trials investigating olanzapine, aripiprazole, quetiapine, and risperidone in elderly demented patients with behavioral disorders, 15 showed a numerical increase in mortality in the drug-treated group compared to the placebo-treated groups (1.6-1.7 times increased risk of death). Specific causes for these deaths were heart-related events (heart failure and sudden death) and infections (mostly pneumonia). The atypical antipsychotics are not currently approved for the treatment of elderly patients with dementia-related psychosis. Therefore, it is important to individually assess and balance the risk versus benefit of antipsychotic use in this population.

Differentiating between depression and dementia can be difficult, so symptoms of depression should be documented for several weeks prior to initiating therapy for the treatment of depression with AD. Citalopram and sertraline are recommended as firstline agents because of their efficacy in placebo-controlled trials.50 Indications for the use of antidepressants include depression characterized by poor appetite, insomnia, hopelessness, anhedonia, withdrawal, suicidal thoughts, and agitation.

Other miscellaneous therapies for AD include benzo-diazepines for anxiety, agit-

ation, and aggression. However, their routine use is not advised. Additionally, benzodiaze-pines have been associated with an increase in falls leading to the potential for hip fractures in the elderly.51 Buspirone has shown benefit in treating agitation

52 53

and aggression in a limited number of patients with minimal adverse effects. ' In open-label and controlled studies, selegiline decreased anxiety, depression, and agita-tion.54,55 Finally, trazodone has been shown to decrease insomnia, agitation, and dysphoria, and has been used to treat sundowning in Alzheimer's patients. Figure 35-2

also provides a treatment algorithm for the behavioral symptoms of AD.

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