By Priya Priyambada, MD
AGEC Geriatric Fellow
Assistant Professor, College of Medicine Geriatrics
University of Arkansas for Medical Sciences
The elderly population is the fastest growing cohort of people in the United States. The number of Americans 65 and older is approximately 46 million presently but this number is projected to double by 2060, comprising 24% of the U.S. population. As dementia is a disease of elderly people, prevalence of dementia continues to rise with this shift in the population dynamics. According to the Alzheimer’s Association, there were 5.7 million people with dementia in the United States in 2018.
As dementia progresses, in addition to the problems with physical health, behavioral disturbances become more frequent. Studies have shown that up to 80% of the patients with dementia may suffer from behavioral disorders and these continue to worsen with the progression of dementia.
The behavioral disturbances are broadly categorized into mood disorders, psychotic disorders, sleep problems, agitation or aggression and disinhibition. These neuropsychiatric symptoms lead to functional impairment in patients with dementia resulting in premature nursing home placement.
Common mood disorders include anxiety, depression and mania. Depressive symptoms often occur early in dementia when patients still have some insight and are either aware of their decline or have been diagnosed as having dementia. The diagnosis of dementia can be frightening for the patient and symptoms can range from sadness and tearfulness to a total lack of interest in activities and apathy. There may be neglect in self-care activities such as grooming, feeding and reduced socialization. Patients with dementia should be screened for depression and appropriate treatment should be started. Careful attention should be given to the side effects and interactions of anti-depressants with the medications the patient is already taking. Patient can also have irritability and impulsivity leading to agitation and aggressive behavior which can endanger the patients as well as caregivers. In many cases behavioral symptoms can occur concomitantly with evidence of paranoia or delusional thinking or hallucinations which are termed as “psychotic” symptoms. Behavioral symptoms with features of hyperactivity, mood lability, disinhibition and grandiose belief can occur occasionally that resemble manic episodes associated with bipolar affective disorder. When it is unclear if the neuropsychiatric symptoms are related to dementia or when other strategies of non-pharmacological management are needed, a referral to a neuropsychologist is highly recommended. Neuropsychologists can provide counseling for the patient and well as caregivers.
As people age, sleep generally becomes lighter and more fragmented causing frequent arousals and awakenings during the night. Changes in sleep patterns can worsen with dementia leading to insomnia, reversal of sleep awake cycle or hypersomnia. Sleep also becomes more disorganized during acute illness and during hospitalization. Following good sleep hygiene and being physically active during daytime is helpful for a good night’s sleep. Non-sedating medications like melatonin are preferred if pharmacological intervention is required.
Behavioral disturbances can have significant impact on the wellbeing and quality of life of patients and caregivers. The worsening of behavior in individuals with dementia is the leading cause of caregiver stress, repeated hospitalizations, increased utilization of health care facilities, nursing home placements, and ultimately increased economic burden for the family and society. Neuropsychiatric symptoms described above may also be the first indication of dementia even before cognitive decline is recognized.
Although behavioral disturbances can accompany dementia, whenever there is an abrupt change in dementia, it is termed an acute change in mental status or delirium. Delirium can occur in any older adult who is severely ill. However it occurs frequently in patients with dementia even with minor illness and is called delirium superimposed on dementia. Delirium requires rapid clinical evaluation with laboratory tests and often requires hospitalization. A patient with delirium can appear agitated (hyperactive delirium) or quiet and depressed (hypoactive delirium). The common and treatable causes of delirium, both hyperactive or hypoactive, include acute illness like urinary tract infections, respiratory infections, metabolic abnormalities or the side effects of medications. It is important to diagnose delirium and not mistake it for worsening dementia because unlike dementia, delirium is quite reversible with appropriate treatment of the underlying cause.
Some behavioral disturbances are inevitable with worsening of dementia, and measures should be taken to provide education on dementia to family members, close friends, nursing staff, social workers, geriatricians and other healthcare providers and ensure a good support system. As the causes of behavioral disturbances are multifactorial, management should be comprehensive and multidisciplinary. Non-pharmacological interventions should always be used as first-line treatment in the management of behavior symptoms in dementia. The important non-pharmacologic measures are listed below:
- Evaluation and treatment of underlying medical conditions: reversible and common causes like pneumonia, urinary tract infections, other systemic infections; fever; dehydration; electrolyte disturbances; thyroid disorders; hypo- and hyperglycemia should always be considered in the evaluation of the behavioral disturbances. Prompt treatment of these conditions is rewarding, can avoid hospitalizations or reduce the length of stay and should always be the priority in the care of people with dementia.
- Review of medications: it is very crucial to review medication history in detail. Use of medications that affect the central nervous system and withdrawal from medications with addictive potential can lead to behavioral disturbances. Avoiding medications like benzodiazepines, antihistamines, anticholinergics (atropine, benztropine, scopolamine) and opioids are the cornerstone for the management of behavioral disturbances. It is important to ask and counsel patients and caregivers about alcohol use and over-the-counter medications for insomnia, allergies or cough that might aggravate behavioral issues.
- Pain management: pain is an important source of behavioral disturbances in patients with dementia. There should be good balance between adequate pain management and avoiding opioids. Chronic pain should be managed with non-pharmacological measures like physical therapy and with non-opioids like acetaminophen.
- Miscellaneous: other nonpharmacological interventions like orientation of day and night with blinds up during the day and lights switched off at night time, minimizing noise and disturbances at night-time, ensuring presence of family member(s) at bedtime as much as possible especially at night time, ensuring adequate sleep at night, avoiding arguments with the patients. Restrains are commonly used specially in hospitals and nursing homes when these patients develop agitation or aggression. However, using restraints is not good practice and the agitation gets worse with restraints and these should be avoided.
The non-pharmacologic therapies like aromatherapy, exercise training, music, art, pet therapy and caregiver education have also demonstrated some benefit for the behavior symptoms.
Pharmacologic treatment of behavioral disturbances in dementia is of limited efficacy. It should be used only after environmental and non-pharmacologic interventions have been implemented and tried.
Anti-dementia medications like cholinesterase inhibitors may have additional benefit for cognition and function and hence can be used for patients with neuropsychiatric symptoms and mild to moderate dementia. Patient with behavior disturbances secondary to Lewy body dementia may also receive benefit from acetylcholinesterase inhibitors.
Antidepressants should be considered in patients with dementia who are experiencing mood symptoms like anxiety, depression, resulting in significant distress or functional impairment. Serotonin receptor uptake inhibitors have been a preferred choice for their favorable adverse-event profiles. Studies have demonstrated the efficacy of sertraline and citalopram versus placebo.
If the non-pharmacological measures are unsuccessful for the neuropsychiatric symptoms in dementia, particularly psychosis, and if there is imminent danger to patient or caregiver due to agitation and aggression, antipsychotics might be needed. Both first and second generation antipsychotics have been identified with increased mortality and adverse-events. Evaluation of the cardiac rhythm and electrolytes needs to be performed at the commencement of these medications and at regular intervals thereafter. Therefore these medications should always be used short-term when possible, with regular reassessments of risks and benefits.
In brief, behavioral disturbances in dementia can be quite challenging and the role of education and support cannot be over-emphasized. A multidisplinary approach with geriatric focused healthcare providers, including neuropsychologists, nurse educators, pharmacists and social workers might provide the greatest benefit for the patient and caregiver dyad and improve their quality of life.
- Alzheimer’s Association, 2018
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- Geriatrics at your Fingertips, 17th edition, New York, American Geriatric Society 2015