Management of Problems Associated with Dementia

General Principles
Delusions or Paranoia
Agitation or aggression
Depression

General Principles in Managing Behavioral Problems

Behavioral problems commonly coexist with cognitive deficits during the course of Alzheimer's and other dementing diseases. They cause significant morbidity, interfere with the performance of activities of daily living, and often have a greater impact on the quality of life of family and caregivers than cognitive impairment.

Common non-cognitive disturbances are delusions (usually accusatory), behavioral abnormalities such as agitation, aggression, incontinence, wandering, depression, and psychiatric phenomenon. Treatment is often challenging and requires education of family members/caregivers, communication between all persons involved in patient care, in addition to the standard pharmacologic and non-pharmacologic interventions.

Before treatment can be initiated, specific identification of the type of behavioral abnormality is essential in determining which symptoms may be amenable to pharmacologic treatment. Symptoms considered responsive to pharmacologic intervention include physical and verbal agitation, depression, and delusional and psychotic symptoms.

General measures to minimize co-morbid problems in dementia

Remember that elderly people have slower metabolisms and often respond to 1/6 to 1/2 the minimum adult recommended dosage.

Treat concomitant medical problems. People with AD and other dementias have just as many medical problems as non-demented patients, and they are often missed because of communication problems.

Caregiver Measures

Make sure the caregiver is not neglecting their own personal or healthcare needs. They should attend support groups to get information for managing the dementia and to get emotional support. Caregiver depression or insomnia are common. Caregivers often die before their demented spouse because they neglect their own medical problems.

Adult Day Care for Moderate to Severely Demented Persons

Environmental stimulation is key to preserving and sometimes improving abilities. Adult Day Care centers provide physical and social activities, stimulation, a meal, and a sensitive environment which can improve behavior. They can help reduce wandering, restlessness, depression, anxiety, insomnia, weight loss, loss of appetite, and abusive behaviors. They also help provide some free time for overstressed caregivers, and improve the quality of time spent between caregiver and the person with dementia. The local Alzheimer's Association chapter can provide you with the nearest location.

Alternative to Adult Day Care

A concept similar to the Adult Day Care centers when they are not available can be beneficial. The key is to provide structured physical and social activities, as well as mental stimulation in terms of repetitive procedures. This can improve behavior, plus reduce wandering, restlessness, depression, anxiety, insomnia, weight loss, loss of appetite, and abusive behaviors that arise from isolation and inactivity.

Support Groups

Support groups for the offspring, spouse and any other caregivers are very important. They provide social support, education for difficult management problems, and an emotional outlet for the caregiver. The local Alzheimer's Association will be able to indicate the nearest one to you.

Delusions, hallucinations or illusions (psychosis)

Delusions
A fixed, unshakable belief that is false and occurs only with that individual.

Hallucinations
Seeing, hearing, feeling, or smelling events that are not present.

Illusions
An altered perception of events that are present through seeing, hearing, feeling, or smelling them.

Psychosis only needs to be treated if it interferes with the patient, caregiver or family in a meaningful way. Patients with such symptoms often have other co-morbid symptoms such as wandering, incontinence, agitation and altered sleep-wake cycles.

The preferred treatment is environmental manipulation because the dopamine antagonists are the only effective medication, and they often have unacceptable side effects or worsen the dementia. Identifying the source of the psychosis and correcting or eliminating it is best. Some examples include:

Ignoring false accusations because they are due to the disease.
Keeping lights or music on if reduced sensory input triggers the psychosis.
Having a regular activity program to increase motor and social activity.
Distracting the patient from their focus of concern by shifting subjects or changing location.
Providing familiar objects for the patient in common locations
Providing them something familiar and reassuring to hold such as their wallet or purse.
Comforting and reassuring the patient through touch and tone of voice.

When dopamine antagonists are indicated, they should be chosen according to their side effect profile to minimize the side effect least desired, or sometimes to maximize a desired side effect. For example:

Molindone (Moban), 5-30 mg po qhs to bid, or risperidone, 0.5-2 mg po qhs to bid, causes less rigidity, slowed movement and hypotension than others.
thioridazine (Mellaril), 25-75 mg, qhs to bid causes less rigidity and slowed movement, moderate to low hypotension, and more sedation than others.
loxapine (Loxitane), 10-60 mg daily, causes less sedation and hypotension than others.

Behaviors associated with agitation and aggression

These behaviors tend to occur in persons with the following risks:

moderate cognitive impairment
premorbid personalities with such tendencies
poor relationship between patient and caregiver prior to the illness
older age
brain damage to structures affecting perception and inhibitory control, especially frontal and temporal lobes.
new onset of a medical illness such as infection

Treatment should first be directed at identifying any undiagnosed medical illnesses, or any precipitants of these disruptive behaviors, including:

pain
hypoxia
drug toxicity
infections
electrolyte imbalances
dehydration

Behavioral treatment of agitation or aggression

Environmental management consists of:

avoiding events that precipitate the behavior
removing the precipitating and perpetuating stimuli
distracting the patient
providing emotional support.

Medical treatments of agitation or aggression

Contrary to common prescribing behavior, antipsychotics are not necessarily the best choice because of the significant and major side effects associated with their use. Also, animal models of aggressive behavior implicate serotonin and catecholamine disturbances in neurotransmission as primary causes of aggressive behavior. Correction of these disturbances often resolves the aggression. Since these agents are generally safer than dopamine antagonists, they should be tried first (primum non nocere). One should also note that it appears that dopamine antagonists decrease brain serotonin levels, which may explain the paradoxical increase in aggressive behavior sometimes seen when they are given to demented patients. Dopamine per se does not affect aggression, but rather operates on the ability to effect aggression by reducing motor output. From a safety perspective, the following drugs should be considered as a first choice treatment:

Sedating serotoninergic agents, especially trazodone, 50-200 mg at h.s. Monitor for hypotension.
Non-sedating selective serotoninergic reuptake inhibitors
low dose beta-blockers, such as propranolol, 10-30 mg po qam to tid, with dose changes of 10 mg every 3 days.
Carbamazepine at low doses (as low as 50 mg twice a day to 200 mg tid), monitoring blood levels and CBC for leukopenia.
Buspirone, a non-sedating anxiolytic, 5-20 mg po bid to tid, with 5 mg dose adjustments every 3 days as needed.

The following drugs should be considered as a second line of treatment:
low doses of selective D2-receptor antagonists will minimize extrapyramidal side effects (risperidone, 0.5-2 mg po qhs to tid, or molindone, 5-20 mg qhs to bid)
if one wants to produce extrapyramidal side effects, then low dose Haloperidol (0.125-1 mg po qhs to bid) titrated according to clinical response.
short-acting benzodiazepines, such as oxazepam or temazepam, 15-30 mg can be useful for episodic treatment. They can also produce paradoxical increase in aggression or agitation, presumably because of the abnormally increased ratio of GABA:glutamate receptors, at least in AD.

Depression

Is it Depression or Dementia?

Depression often coexists with dementia. In AD, it tends to occur in the earlier stages of the disease when the patient still has awareness about their problem. Many AD patients lose awareness about their dementia by the latter part of the mild stage, and consequently, do not experience as much depression as some other dementias such as vascular or multi-infarct dementia or parkinson's dementia. Depression alone can also resemble dementia and is often only diagnosed by formal cognitive testing. Since dementia due to depression is treatable and reversible, it is important to distinguish depression alone from depression secondary to another cause of the dementia.

Management of Depression

For depression and associated symptoms, if behavioral approaches (e.g., adult day care, activity groups, exercise, pets) alone do not help, then medical treatment is indicated.

Depression with Problems Sleeping

If insomnia coexists, then an antidepressant that helps sleep should be given one to two hours before bedtime. The ones with the fewest anticholinergic side effects (dry mouth, confusion, incontinence) should be used in demented persons. The dosage should be the smallest one that gives the person a full night of sleep. The full antidepressant effect can take up to three weeks. Dose titrations are done on a weekly basis unless otherwise indicated. These agents include:

trazodone (Desyrel), 50-200 mg, increasing by 50 mg increments each night.
nortryptiline (Pamelor), 10-50 mg daily in one or two divided doses. Monitor the electrocardiogram for sinus tachycardia and prolonged conduction time.

Depression without sleeping problems

If no sleep problems exist, then one can use one of the selective Serotonin reuptake inhibitor antidepressants in the morning:

Most Common Side Effects

Side effects can include nervousness, dizziness, rapid heart rate, constipation, loss of appetite, headache, sweating, tremor, dry mouth, confusion, and (rarely) convulsions. Dosage adjustments are usually needed with all of these medications, which take at least two weeks to become fully effective.

Zoloft

A safe antidepressant is sertraline (Zoloft), 50-200 mg in the morning. Zoloft has the least interaction with the P450 enzyme system in the liver, which means that it will have fewer interactions if other medications are being used. Zoloft can also be used to help persons with difficulty waking up in the morning by giving 50 mg at bedtime.

Other Selective Serotonin Reuptake Inhibitor Antidepressants

The other antidepressants of this type include:

Fluoxetine (Prozac), 10-40 mg po qam.
Bupropion (Wellbutrin),75 mg, po qam to tid
Paxil, 10-40 mg, qam (a phenylpiperidine, unlike the other SSRIs)
Desipramine, 10-100 mg in the morning with food.

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