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AUTHOR: DR. SHAHUL AMEEN, M.D.

2.2.4 MANAGING THE BEHAVIORAL PROBLEMS IN DEMENTIA

Behavioral symptoms can arise as a result of the dementing illness, a concomitant medical illness, or iatrogenic causes. A common error in management of behavioral disturbances is to treat them without identifying the symptom precipitant. Before treatment is instituted, disruptive behavior should be categorized and underlying causes sought. Unless both the physician and the patient's family have a clear understanding about the behavior being treated and the goals of treatment, the results are often unsatisfactory (Burke and Morgenlander, 1999).

Depression

Patients with dementia commonly have impaired insight, which makes psychotherapy useless. Thus, treatment primarily consists of pharmacotherapy, but physical and mental activity can be helpful in minimizing symptoms. When drug therapy is required, a selective serotonin reuptake inhibitor (SSRI) is a reasonable first-line treatment. Tricyclic antidepressants with low anticholinergic activity (for e.g., desipramine) are effective in patients with dementia and are less expensive than SSRIs. Tricyclic agents with prominent anticholinergic activity (eg, amitriptyline) should be avoided, as they tend to worsen cognitive impairment and precipitate delirium. When marked apathy is present, a more activating antidepressant that stimulates both the serotonergic and adrenergic neurotransmitter systems (eg, fluoxetine, venlafaxine) is useful. For patients in whom insomnia is a prominent feature of depression, trazodone is an effective sedating antidepressant (Burke and Morgenlander, 1999).

Sleep disturbance

Many factors can contribute to poor sleep habits in persons with dementia, including disrupted sleep patterns, alterations in circadian rhythm, concurrent medical problems that cause frequent urination, daytime use of sedating medication, and frequent napping. Educating families about strategies for preventing or correcting sleep problems may help delay nursing home placement. The first step in reestablishing a normal sleep pattern is to limit daytime napping. Caregivers should engage patients in activities that are tailored to the degree of dementia, such as simple handicrafts, household tasks and, most important, regular physical exercise. The patient's activity level should be increased, and fluid intake should be decreased in the hours before bedtime. After a few difficult nights, the patient will begin to sleep for longer periods. For families who cannot accept the possibility that the problem will worsen before improving, limited use of a hypnotic or sedating drug may be considered. However, long-term reliance on sleeping medication, especially benzodiazepines, is rarely successful (Burke and Morgenlander, 1999).

Agitation and aggression

The first step in management of aggression is identification of precipitants like infection, dehydration, constipation, other illnesses and changes in medication. Families should be informed about potential causes of agitation, such as excessive stimulation, and about the need to make educated guesses about circumstances that trigger inappropriate behavior. Patients with dementia often become agitated when rushed; therefore, avoiding time-critical events, if possible, is useful. The patient's day should be structured to provide a predictable routine. Orientation materials (eg, calendar, clock, family pictures) should be prominently displayed, and the living environment should be well lit, even in the daytime, to avoid misperception of stimuli. Behaviors that are disruptive but not harmful (eg, pacing) should be tolerated (Burke and Morgenlander, 1999). Physical restraint is rarely necessary and usually serves to escalate the degree of agitation.

If environmental measures are insufficient to control the behavior, medication is needed. High-potency neuroleptics are effective for controlling agitation, especially when psychotic features are present (Small et al., 1997). The atypical antipsychotics have a lower frequency of extrapyramidal side effects, and are very useful in patients with Parkinson's disease because their selective dopaminergic blockade does not interfere with dopamine's therapeutic effect in the basal ganglia. However, cerebrovascular adverse effects (e.g., stroke, transient ischemic attack), including fatalities, were reported in trials of risperidone in elderly patients with dementia-related psychosis (Brodaty et al., 2003). Benzodiazepines can also be used to treat anxiety or infrequent agitation, but they are less effective than other agents for long-term treatment. Other medications found effective in treating behavioral disturbances in dementia include carbamazepine (Tariot et al., 1998), divalproex sodium (Narayan and Nelson, 1997), propranolol (Shankle et al., 1995), and the acetylcholinesterase inhibitors donepezil and tacrine (Levy  et al., 1999).

In general, when agitation is a consistent problem and neuroleptic treatment is required, start with a low dose (eg, 0.5 mg of haloperidol or 1 mg of risperidone) and administer it on a regular basis rather than attempting to treat specific episodes of agitation. Trying to treat a patient who is already agitated makes administering medication difficult, requires larger doses, and is likely to cause sedation and further clouding of thought. The need for continued pharmacologic treatment of agitation should be regularly reassessed, and medication for agitation should not be viewed as long-term therapy (Borson and Raskind, 1997).

Delusions and hallucinations

Before pharmacotherapy is initiated, the cause of the psychosis (eg: onset of another illness, a medication effect, etc.) should be determined, if possible. If no cause is found, environmental changes, such as increased lighting and decreased social isolation, can help. Nonthreatening delusions and hallucinations need not be treated. Families should be reassured about the benign nature of these features and informed of the potential side effects of drug therapy. When short-term pharmacologic treatment is needed, it should be initiated with low doses of a high-potency or atypical antipsychotic. Haloperidol is effective in patients with dementia, but dosages higher than 3 mg a day often lead to excessive sedation and parkinsonian side effects (Burke and Morgenlander, 1999).

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