Department of Psychiatry, Yale University School of Medicine, New Haven, USA
*Corresponding author:
Rajesh R. Tampi
Associate Clinical Professor of
Psychiatry
Yale University School of Medicine, New Haven, USA E-mail:
rajesh.tampi@yale.edu
Received May 03, 2012; Accepted May 05, 2012; Published May 07, 2012
Citation: Tampi RR (2012) Treating Behavioral Disturbances in Dementia,
Using Evidence to Optimize Care. J Addict Res Ther 3:e104. doi:10.4172/2155-6105.1000e104
Behavioral disturbances in dementia are a group of noncognitive
symptoms and behaviors that occur frequently in patients
with dementia [1]. They can be defined as a heterogeneous range of
psychological reactions, psychiatric symptoms and behaviors that
are unsafe, disruptive and impair the care of the patient in a given
environment [1].
Behavioral disturbances occur in about a third of communitydwelling
people with dementia but their prevalence rises to over 80%
in patients admitted to skilled nursing facilities [1]. Unlike cognitive
symptoms of dementia which decline over the course of the illness,
behavioral disturbances often fluctuate with agitation being the most
persistent symptom [1].
Behavioral disturbances in dementia can be grouped into different
symptom clusters [2]. These include the psychotic cluster (delusions
and hallucinations), agitation, mood disorders cluster (depression and
anxiety; apathy-indifference), aberrant motor behavior cluster (pacing,
wandering, and other purposeless behaviors) and inappropriate
behavior cluster – disinhibition and euphoria. Apathy appears to be
the most common behavioral symptom in dementia with a prevalence
rate of 48% to 92% [3].
Available data indicates that behavioral disturbances in dementia
occur due to a complex interplay between neurobiological changes
associated with dementia, psychological traits and genetics [1,4].
Neurobiological changes include pathological and functional changes
within the frontal, parietal and temporal cortices and the basal ganglia.
High levels of neuroticism predispose patients to these behaviors.
Genetics of behavioral disturbances in dementia include the presence
of APOE3/4 genotype and the polymorphisms of the serotonin and
dopamine receptors [1].
The presence of behavioral disturbances in dementia is associated
with significantly higher social and economic burden of care [1]. They
also increase the risk for institutionalization for these patients. These
behaviors are associated with a faster cognitive and functional decline
and a worse quality of life. They also add to the direct and indirect costs
of caring these patients [1].
Evaluation of patients with behavioral disturbances in dementia
must include a thorough medical and psychiatric history [5]. Common
reversible conditions including metabolic, infectious and nutritional
and neurovascular disorders must be ruled out. The effect of medications
on the development of these symptoms should be evaluated. The use
of standardized rating scales assist in qualifying and quantifying these
behaviors and aid in monitoring their progress during treatment [6].
Current evidence indicates efficacy for both non-pharmacological
and pharmacological treatments for behavioral disturbances of
dementia [7]. Pharmacotherapy is usually reserved for those patients
who have had an inadequate response to non-pharmacological
interventions and is often used in combination with the nonpharmacological
interventions [7].
A systematic review of evidence indicates that caregiver and
residential care staff education and possibly cognitive stimulation in patients appeared to have lasting effectiveness in the treatment of
behavioral disturbances in dementia [8]. Behavioral management
techniques centered on individual patient’s behavior are often
successful for the reduction these behaviors. Availability of supports
systems for the patients and their caregivers with greater time for
self and providing education and training to the caregivers reduce
caregiver burden and have a positive impact on the patient behaviors
thus delaying institutionalization [7].
Meta-analytic evidence indicates that atypical antipsychotic
medications; risperidone and aripiprazole have some albeit modest
effects on the treatment of behavioral disturbances in dementia [9].
Available data indicates limited benefit for olanzapine and quetiapine
for the treatment of these behaviors [7]. The use of these medications
is limited by their side-effect profile and associated direct and indirect
costs. Current data does not indicate significant benefit for these
medications in reducing the financial costs and the burden of care of
these patients [7].
The data on the use of anticonvulsants in the treatment of
behavioral disturbances is disappointing with limited benefit noted
for carbamazepine [10]. Antidepressants especially selective serotonin
reuptake inhibitors have shown some benefit in treating the mood
disorder cluster of symptoms but again this data is limited [11].
Benzodiazepines have minimal role in the treatment of behavioral
disturbance in dementia given the lack of data on their efficacy and
significant adverse effects. Cholinesterase inhibitors and memantine
have limited data on treating behavioral disturbances in dementia
although they may delay the emergence of these symptoms by delaying
the cognitive decline [7].
Recent concerns on the use of psychotropic medications in the
treatment of behavioral disturbances in dementia especially the
antipsychotics include the increased risk of cerebrovascular adverse
events and death [12]. Available evidence indicates that the risk is
similar for all the different antipsychotics. Emerging data implicates
the valproic acid derivatives and benzodiazepines with similar risks
[13,14]. The risk for these adverse effects appears greatest within the
first month of treatment initiation and the risk remains for up-to two
years. The risk for these adverse events is higher in older patients and is
those patients with vascular dementia, more severe stages of dementia
and in patients with cardiovascular risk factors and functional impairments [12].
Given the current state of evidence, it is clear that the assessment
and treatment of behavioral disturbances in dementia needs further
refinement. A thorough medical evaluation will aid in the diagnosis
and treatment of medical conditions that can cause or worsen these
behaviors. This medical evaluation can assist in the prevention
of unnecessary exposure to psychotropic medications. The use
of standardized assessment scales can qualify and quantify these
behaviors. They can assist with the assessment of severity or the stage
of dementia. Education of the staff and caregivers along with cognitive
simulation in the patients can reduce the frequency and severity of
these behaviors. For those behaviors resistant to non-pharmacological
interventions, pharmacotherapy can be instituted. Careful clustering
of symptoms, identifying target symptoms, using medications that
have best evidence in treating these target symptoms, close monitoring
of symptom improvement with frequent assessment for adverse
effects of medications can maximize gain and minimize loss with
pharmacotherapy. The combination of non-pharmacological and
pharmacological treatment modalities appear to have a synergistic
effect and should be the norm and not the exception for the treatment
of more severe behaviors. As newer data emerges for the assessment
and treatment of behavioral disturbances in dementia, this data should
be added to the treatment algorithm to optimize outcomes for these
patients and their families.
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