Psychiatric Assessment and Treatment of Nonpsychotic Behavioral Disturbances in Dementia

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Anton P. Porsteinsson, J. Michael Ryan, M. Saleem Ismail, and Pierre N. Tariot

In addition to core cognitive and functional deficits, neuropsychiatry symptoms, emotional disorders, and behavioral alterations are ubiquitous among patients with dementia syndromes. Clinicians should be concerned with the behavioral signs and symptoms of Alzheimer's disease (AD) and other dementias because they are prevalent, distressing to the patient, and upsetting to caregivers. Often they contribute significantly to the need for institutional care. A previous cross-sectional multicenter study of several hundred outpatients with AD found that no patient had been free of behavioral signs or symptoms in the preceding month (Tariot, Mack, et al., 1995). A population-based study of dementia found a point prevalence of psychopathology of more than 60% and asserted that the lifetime risk of psychopathology for a patient with dementia approached 100% (Lyketsos et al., 2000). These figures make clear that it is important to know how to recognize and manage the behavioral manifestations of dementia.

Behavioral and psychological signs and symptoms of dementia are heterogeneous and can be difficult to categorize, even for the expert. However, clinical experience and studies teach us that certain symptom patterns can be discerned; a relatively recent consensus conference on the issue asserted in a summary statement issued by the International Psychogeriatric Association that behavioral signs and symptoms occur commonly and can include observable motor and verbal behaviors as well as psychological phenomena (Finkel, Costa e Silva, Cohen, Miller, & Sartorius, 1996). These signs and symptoms, summarized in Table 12.1, do not meet the usual criteria for

Table 12.1 Summary of Literature Regarding Psychopathology of Dementia*

Range (%)

Median (%)

Disturbed affect /mood

0-86

19

Disturbed ideation

10-73

33.5

Altered perception

Hallucinations

21-49

28

Misperceptions

1-49

23

Agitation

Global

10-90

44

Wandering

0-50

18

Aggression

Verbal

11-51

24

Physical

0-46

14.3

Resistive/uncooperative

27-65

44

Anxiety

0-50

31.8

Withdrawn /passive/ behavior

21-88

61

Vegetative behaviors

Sleep

0-47

27

Diet /appetite

12.5-77

34

* Percentage of patients affected among studies reviewed.

Adapted from " The Psychopathology of Dementia," by P. Tariot and L. Blazina, 1993. In Handbook of Dementing Illnesses, J. Morris, ed., New York: Marcel Dekker, pp. 461-475.

* Percentage of patients affected among studies reviewed.

Adapted from " The Psychopathology of Dementia," by P. Tariot and L. Blazina, 1993. In Handbook of Dementing Illnesses, J. Morris, ed., New York: Marcel Dekker, pp. 461-475.

major psychiatric disorders and outside of psychosis or depression in AD, they tend to occur in a subsyndromal fashion. As our understanding of these phenomena improves, the language will sharpen. The figures in the table provide a rough estimate of the likelihood of a patient's experiencing a particular sign or symptom. These features tend to fluctuate in individuals over time, and there is tremendous heterogeneity among individuals. For instance, the study of Devanand et al. (1997) found that affective symptoms tend to fluctuate considerably over a year and psychotic symptoms somewhat less so, while agitation tends to emerge as the illness progresses and tends to persist once it has emerged. The main points, however, are that patterns of signs and symptoms can be predicted, and there is a significant degree of heterogeneity among and within patients.

While there is not a uniform relationship between severity of dementia and types of behavioral disturbance, some general trends can be discerned. Depressive and anxious symptoms are relatively common in the mild stages, as are social withdrawal and lack of initiative, which may be interpreted as manifestations of depression but actually might be better understood as apathy. Irritability, delusions (frequently paranoid in nature), wandering, and agitation are most common in moderate stages of illness. In advanced stages, socially inappropriate or disinhibited behavior, repetitive purposeless actions, aggression, or marked apathy can be seen (Jost & Grossberg, 1996). Longitudinal studies have suggested that depressive features tend to fluctuate over a period of months to years and psychotic features somewhat less so, whereas agitation tends to be linked with disease progression and persists once it has emerged (Devanand et al., 1997).

Although our understanding of the underlying neurobiology of AD is advancing rapidly, the etiology and pathophysiology of behavioral and psychological signs and symptoms is far less well understood. The literature is inconsistent most likely because of methodological problems, including qualification and quantification of the behavioral substrates and the fleeting nature of behavioral symptomatology. This suggests that the neurobiological changes of behavior are dynamic, involving biochemical, structural, genetic, and environmental factors rather than static causes alone. It is also highly likely that certain behaviors reflect unmet needs or emotions as well as misapprehension of the behavior of others or of the environment based on cognitive disturbance. Dementia diagnosis may also be an important factor, as evidence mounts that patients with AD, vascular dementia (VaD), dementia with Lewy bodies, dementia of Parkinson's disease, and frontotemporal dementia have varying clinical presentations. In conclusion, these complex behavioral phenomena will probably be understood best as multidetermined.

Agitation is the paradigm of psychopathology addressed in this chapter because the principles pertaining to treatment of agitation are easily applied to treatment of other behavioral signs and symptoms. In caring for a patient with dementia and agitation, we rely on a systematic approach to evaluation and management that has been articulated previously (Loy, Tariot, & Rosenquist, 1999; Rosenquist, Tariot, & Loy, 2000; Tariot, 1999). The key general elements in this approach are summarized in Table 12.2, which emphasizes clarification of target symptoms, ruling out delirium or occult major psychiatric diagnoses, and creatively addressing possible social, environmental, or behavioral remedies. There are excellent reviews of nonphar-macological interventions in other chapters in this book. Only in emergent situations or when these nonpharmacologic interventions have failed should medications be deployed.

Table 12.2 Summary of General Principles to the Approach of Agitation and Aggression in Patients with Dementia

1. Define target symptoms.

2. Establish or revisit medical diagnoses.

3. Establish or revisit neuropsychiatric diagnoses.

4. Assess and reverse aggravating factors.

5. Adapt to specific cognitive deficits.

6. Identify relevant psychosocial factors.

7. Educate caregivers.

8. Employ behavior management principles.

9. Use psychotropic medications for specific psychiatric syndromes. 10. For remaining problems, consider symptomatic pharmacotherapy:

• Use psychobehavioral metaphor.

• Use medication class relevant to metaphor and with empirical evidence of efficacy.

• Use lowest effective dose.

• Withdraw after appropriate period, observe for relapse.

• Serial trials sometimes needed.

Adapted from "Treatment of Agitation in Dementia," by P. N. Tariot, 1999, Journal of Clinical Psychiatry, dO(Suppl. 8), pp. 11-20.

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