Antipsychotics For Behavioral Disturbance In Dementia A Clinical Conundrum
Judith A. Neugroschl, MDPsychiatric Times
Although the adverse-effect profile of older, conventional antipsychotics has discouraged many clinicians from using them, they remain widely used in elderly patients with dementia.
Although cognitive and functional decline are the cardinal features of dementia syndromes, the associated neuropsychiatric symptoms are some of the most common and troubling manifestations of these debilitating diseases. These symptoms include agitated or aggressive behaviors, such as yelling, biting, and hitting, and psychotic symptoms, such as paranoia and hallucinations. Given that an estimated 5.4 million Americans have Alzheimer disease and that neuropsychiatric symptoms eventually develop in 60% of community-dwelling patients and more than 80% of nursing home patients, one can appreciate the scope of this problem. Moreover, these symptoms are exceedingly difficult for both clinicians and families to manage, making this a particularly relevant aspect of caring for patients with dementia.
As common and debilitating as these symptoms are, clinicians have few ways of adequately addressing them. There are no FDA-approved treatments for patients with dementia-related agitation or psychosis. Moreover, historical accounts of treatment of nursing home patients with such mental disorders and recent data on the risks of using antipsychotic medications in this population have made choosing a course of action even more complex.
Trajectories Of Behavioral Disturbance In Dementia
Article type: Research Article
Affiliations: Rotman Research Institute of Baycrest, Toronto, ON, Canada | University of Toronto Faculty of Medicine, Toronto, ON, Canada | University of Toronto Dalla Lana School of Public Health, Toronto, ON, Canada | University of California at San Francisco Memory and Aging Center, San Francisco, CA, USA
Correspondence: Correspondence to: Tiffany Chow, MD, Senior Scientist, Rotman Research Institute, Baycrest Brain Health Complex, 3560 Bathurst Street, Toronto, ON M6A 2E1, Canada. Tel.: +1 416 785 2500 ext. 3459; Fax: +1 416 785 2862; E-mail: .
Keywords: Agitation, Alzheimer’s disease, apathy, behavioral symptoms, disease progression, frontotemporal dementia, longitudinal study, neurobehavioral manifestations
Journal: Journal of Alzheimer’s Disease, vol. 31, no. 1, pp. 143-149, 2012
Other Factors Associated With Bpsd
Besides the influence of dementia stage and subtype on the emergence of BPSD, other factors such as demographic variables and the use of medication have not been extensively explored. A number of associations, albeit not consistently replicated, have been described between neuropsychiatric symptoms, and patient-related or environmental factors.
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The Effects Of Behavioral Disturbances On The Person With Dementia
For the people around the person with dementia, it is important to understand that the behavior of their relative could be related to their illness. Although they may not be able to handle it, these reactions could cause panic and stress for family members and caregivers.;
It is important for the family members and caregivers to be open about their needs so they can receive support. This will help them feel confident because they wont feel unimportant or weak.
It is important to understand that events and conversations could trigger the behavioral problems of dementia.
For instance, a person who experienced a lot of loss or had an unhappy childhood may decline in behavior due to these events. However, family members and caregivers should not be more hurt because of their reactions. Instead they should understand their behavior and try to be gentle even if they are aggressive most of the time.
In short, it is important to know that behavioral disturbances in dementia are common and can be treated. Family members and caregivers should not feel guilty for the reactions of their loved ones. Instead they should try to learn how to live with them more comfortably.
Is Lewy Body Dementia An Inherited Condition
One of the more recent discoveries toward identifying a cause of Lewy body dementia is the finding of an increasing number of gene mutations. Two genetic risk factors recently discovered are variants in the APOE and GBA genes. APOE is already known to increase the risk of developing Alzheimers disease. There is growing evidence that it also increases the risk for dementia with lewy bodies. Similarly, the GBA gene increases the risk for both Parkinsons disease and dementia with lewy bodies. Despite these findings, genetic changes as a cause of LBD are still considered rare by scientists. Most cases of Lewy body dementia are not thought to be inherited.
Genetic testing for routine screening for LBD is not currently recommended. Discuss the pros and cons of testing with your healthcare providers if you have a family history of multiple members with Parkinsons disease and/or dementia with lewy bodies.
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What Other Things Help
In addition to medications, there are various ways to help a person with bvFTD. Research has shown that;physical exercise;helps to enhance brain health and improves mood and general fitness. A;balanced diet, enough;sleep and limited alcohol intake are other important ways to promote good brain health. Other illnesses that affect the brain, such as diabetes, high blood pressure and high cholesterol, should also be treated if present.
What Is Lewy Body Dementia
Lewy body dementia , is a brain disorder in which proteins, called alpha-synucleins, build up inside certain neurons . These clumps of proteins, called Lewy bodies, cause damage to neurons in areas of the brain that affect mental capabilities, behavior, movement and sleep.
In elderly patients, LBD is one of the most common causes of dementia. The symptoms of LBD may closely resemble those of other neurological disorders, including Alzheimers disease and Parkinsons disease.
Doctors do not know why you or your loved one develop LBD while others do not. There is no cure for LBD, but your symptoms can be managed with certain medications, like cholinesterase inhibitors and levodopa. You or your loved one may also benefit from non-medical treatments like physical therapy and speech therapy.
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What Are The Symptoms Of Lewy Body Dementia
Lewy body dementia symptoms may resemble those of other neurological disorders, like Alzheimers disease and Parkinsons disease. LBD affects each person differently, and symptoms vary in severity.
Common symptoms of LBD include:
- Visual hallucinations, or seeing things that are not there.
- Reduced alertness, attention and ability to concentrate.
- Parkinsonism, a movement disorder with symptoms including slowness, tremors, stiffness, balance problems, soft voice, difficulty swallowing, reduced facial expression and shuffling walk.
- Visuospatial difficulties, including decreased depth perception, trouble recognizing familiar objects and impaired hand-eye coordination.
- Delusions, or beliefs with no basis in reality.
- Changes in behavior and mood including anxiety, agitation, aggression, apathy, depression and paranoia.
- Changes in sleep patterns.
Other symptoms include:
- Acting out while sleeping. Your loved one may act out their dreams during a phase of sleep cycle called rapid eye movement . Sometimes this happens years before their LBD diagnosis. Often called REM sleep behavior disorder , this condition is described as frequent movements, such as flailing or punching, with yelling or speaking while sleeping. People living with RBD often have difficulty separating dreams from reality when they wake up.
- Changes in normal body functions. Body temperature may waver, blood pressure may fluctuate and loss of bowel and bladder control.
Unspecified Dementia Without Behavioral Disturbance
- 201620172018201920202021Billable/Specific CodeAdult Dx
- F03.90 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
- The 2021 edition of ICD-10-CM F03.90 became effective on October 1, 2020.
- This is the American ICD-10-CM version of F03.90 – other international versions of ICD-10 F03.90 may differ.
- F03.90 is applicable to adult patients aged 15 – 124 years inclusive.
- Applicable To annotations, or
Predicting And Preparing For Behavioral Disturbances In Dementia
There are a few things that could predict behavioral problems. For example, early or advanced stage of the disease could be linked with worse behavior.;
Behavioral disturbances can be also prevented by taking medications and setting up routines for the person with dementia. Being attentive to the behavior of the person with dementia will help set them up for better lives.
The Diagnosis And Treatment Of Behavioral Disorders In Dementia
Background: Behavioral disorders such as aggressiveness, agitation, delusions, disinhibition, affect lability, and apathy arise in more than 90% of patients with dementia. Behavioral disorders are a major challenge and the greatest stress factor in everyday life for nursing personnel and for family members caring for the patient.
Methods: This review is based on relevant publications retrieved by a selective literature search in the PubMed, Cochrane Library, and German S3 guideline databases with the search terms behavioral disorders, non-cognitive disorders, and challenging behavior, in conjunction with dementia and behavioral and psychological symptoms of dementia.
Results: Behavioral disorders regularly accompany dementing illness and have identifiable and treatable somatic and environment-related causes. They should be treated symptomatically, both with non-pharmacological measures and with drugs. Memory therapy , ergotherapy , music therapy , and physical exercise are effective, as are anti-dementia drugs . Risperidone is the drug of choice to combat agitation and aggressiveness as well as dementia and hallucinations . Citalopram can be recommended for the treatment of depression in patients with dementia .
Etiology and pathogenesis
Somatic causes of behavioral disorders in dementia
Clinical experience shows that these behavioral disorders sometimes have somatic causes:
Psychological and environmental factors
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How To Deal With Behavioral Disturbances
Dealing with dementia will not become easier, however, one can make it manageable as a caregiver to family members. For instance, keeping a healthy lifestyle can help in maintaining their mood with good sleep habits, healthy meals, regular exercise, and good socialization.
Behavioral disturbances cause a lot of stress and energy for both the patient and the caregiver or family member. There are other ways for you to spend time and deal with their symptoms:
- Be calm when their agitated or irritated
Papers Of Particular Interest Published Recently Have Been Highlighted As: Of Importance Of Major Importance
Alzheimers Association. Alzheimers disease facts and figures. Alzheimers Dement. 2012;8:13168. This reference provide the latest and most comprehensive statistics on prevalence of Alzheimers disease and behavioral disturbances.
Alzheimers Disease International. World Alzheimer Report 2010. London, Alzheimers Disease International; 2010. . Accessed 6 April 2012.
Lyketsos CG, Steinberg M, Tschanz JT, et al. Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging. Am J Psychiatry. 2000;157:70814.
Steinberg M, Shao H, Zandi P, et al. Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study. Int J Geriatr Psychiatry. 2008;23:1707.
Wetzels RB, Zuidema SU, de Jonghe JF, et al. Course of neuropsychiatric symptoms in residents with dementia in nursing homes over 2-year period. Am J Geriatr Psychiatry. 2010;18:105465.
Wetzels R, Zuidema S, Jansen I, et al. Course of neuropsychiatric symptoms in residents with dementia in long-term care institutions: a systematic review. Int Psychogeriatr. 2010;22:104053.
Bergh S, Engedal K, Roen I, Selbaek G. The course of neuropsychiatric symptoms in patients with dementia in Norwegian nursing homes. Int Psychogeriatr. 2011;23:12319.
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How Can A Person Diagnosed With Lewy Body Dementia Live The Best Life Possible
First, its important to interact with others as much as possible. Plus exercise and eat a healthy diet to keep mind and body as strong as possible.
Use music and aromatherapy to reduce anxiety and improve mood.
Other things you can do involve seeking the help and assistance of others. Therapists can improve the quality of life of someone living with Lewy body dementia. Therapists include:
- Physical therapists: These therapists can help improve physical strength, flexibility, balance and walking mechanics.
- Occupational therapists: These therapists can teach skills and methods to maintain your ability to perform activities of everyday life and remain independent.
- Speech therapists: These therapists can improve swallowing difficulties and ability to speak more clearly.
Persons with Lewy body dementia and their families can also benefit from counseling with a psychotherapist. This counselor teaches how to manage emotional and behavioral problems. Finally, joining a support group there are support groups for persons with LBD and for the caregivers of persons with LBD. Support groups help solve day-to-day problems and frustrations through sharing similar experiences. See the resource section of this article for links to support groups.
Interview With The Patient
Although subjects with dementia may be handicapped in their communication and social skills, it is essential to have an individual assessment with them. Whenever possible, it is desirable that patients are encouraged to express their own concerns in answer to open questions before proceeding to a more systematic approach to specific symptoms. Patients free descriptions are least prone to be influenced by the interviewer and/or caregiver and can provide crucial information about emotional states underlying behaviors.
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Ethics Approval And Consent To Participate
This study was exempt from review by an institutional review board because the database was compliant with the Health Insurance Portability and Accountability Act and because the data do not include any identifiable patient information. The data used for this study did not involve the interaction or interview with any subjects and the data does not include any individually identifiable data and as such is not research involving human subject as defined at 45 CFR 46.102. Furthermore, this study used existing fully de-identified and the investigator cannot be identified, directly or through identifiers linked to subjects and as such is exempt from 45 CFR 46.101 from all 45 CFR part 46 requirements.
Monitoring And Dosing Adjustment
The American Diabetes Association and American Psychiatric Association have guidelines for the long-term monitoring of patients receiving antipsychotics .25,26 Physicians should consider the clinical context and anticipated duration of treatment when ordering these tests and monitoring effects. For example, patients with a life expectancy of less than 10 years may not benefit from monitoring for modifiable cardiovascular risk factors. However, regular assessment of dose-related adverse effects, such as extrapyramidal symptoms and sedation, may lead to dose reduction with acute benefits. Because older patients have decreased renal blood flow resulting in decreased renal clearance, assessment of renal function and subsequent dosing adjustments are key to reducing adverse effects in this population. Collaboration with a clinical pharmacist may help in reducing polypharmacy, monitoring for interactions, and making appropriate dose adjustments.27,28
Monitoring Recommendations for Patients with Long-Term Antipsychotic Use
BMI = body mass index.
Monitoring Recommendations for Patients with Long-Term Antipsychotic Use
BMI = body mass index.
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Pathophysiology And Neurobiology Of Bpsd
The behavioral or psychological disturbances occurring in dementia can be understood as ineffective attempts of the patient to cope with environmental or physiological stress factors. Indeed, BPSD are also common in non-demented older adults with rates of 5.6% for anxiety, 4.5% for irritability and 2.8% for agitation/aggression while psychotic symptoms are present in up to 10.5% of Swedish 85 years-old people . It is important, therefore, to trace back these symptoms to premorbid psychosocial functioning which is determined by constitutional factors , past experiences and level of education. Abnormalities in the intensity, magnitude, duration, timing, and modifiability of internal conditions and/or observable behaviors are expected to emerge beyond the limits of normal variability as the ongoing neuropathological changes of dementia undermine the individuals usual psychological capacities to adequately respond to everyday demands. Defining these neuroanatomical and neurochemical correlates of BPSD has been an area of active research with a hope that clarification of the underlying neurobiology will lead to more effective treatments .
Table 6. BPSD and structural changes in neuroimaging exams.
Mental Disorders Due To Known Physiological Conditionsnote
- 201620172018201920202021Non-Billable/Non-Specific Code
- mild memory disturbance due to known physiological condition
- senile dementia with delirium or acute confusional state
- Dementia late onset w hallucinations
- Dementia without behavioral disturbance
- Hallucinations co-occurrent and due to late onset dementia
- Mild dementia
- Severe dementia
- 884 Organic disturbances and intellectual disability
- 974 Hiv with major related condition with mcc
- 975 Hiv with major related condition with cc
- 976 Hiv with major related condition without cc/mcc
- : New code
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Can Dementia Get Worse Suddenly
Dementia is a progressive condition, meaning that it gets worse over time. The speed of deterioration differs between individuals. Age, general health and the underlying disease causing brain damage will all affect the pattern of progression. However, for some people the decline can be sudden and rapid.
How To Handle Behavioral Disturbances Of Dementia
There are different ways of handling behavioral disturbances. It all depends on the person and the severity of it. Remember that there may be a reason why they are behaving this way.
The most common way is through medication; unfortunately, these medications do not work for everyone with dementia. Hence, the second option is to look into other forms of treatment such as physical training, occupational therapy, and art therapy.;
Physical training is important for people with dementia as it increases their appetite and makes them want to be more active. By doing physical training, the muscles of the person would not get weak so that they would not feel depressed or stressed about getting old. Occupational therapy is also important because it may help increase their cognitive abilities and eventually improve their sleeping pattern.;
Art therapy is another option as a way of treating behavioral disturbances. It is very important to have the support of people who care and dont feel afraid to talk about their needs, frustrations or concerns.
The most important part here is communication and support. If a person with dementia feels that family members dont understand them and arent willing to help, they might be offended. This could lead to more behavioral problems for the family. Hence, it is important to be open about the behavioral problems of dementia.