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.
These common dementia-associated neuropsychiatric symptoms carry risks for decreased quality of life, increased cost of care, more rapid cognitive decline, and tremendous caregiver burden. Caregivers often neglect their own physical and emotional needs, which can lead to depression, anxiety, irritability, and insomnia.1-4 When caregivers are burned-out and symptomatic themselves, the risk of substandard patient care, not to mention neglect and abuse, becomes much higher.
Increased caregiver burden, in particular, carries with it significant repercussions for patients and families, because caregiver stress is clearly associated with more rapid patient institutionalization. Apart from the often difficult emotional repercussions from placing a loved one in a nursing home, early institutionalization has obvious financial implications for the entire health care system. Indeed, neuropsychiatric symptoms can shorten the time to nursing home placement by as much as 2 years. Although the data are conflicting, some studies have shown a connection between neuropsychiatric symptoms and increased mortality.5
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 (including dementia-related neuropsychiatric symptoms) and recent data on the risks of using antipsychotic medications in this population have made choosing a course of action even more complex.
Until quite recently, the psychiatric conditions of nursing home residents were often misdiagnosed or ignored. This led to the related problems of neglect or inappropriate treatment, often with physical and so-called chemical restraints. Early data indicated that 25% of 1.3 million nursing home residents were in physical restraints for the control of behavioral problems, despite the potential adverse effects of injury, skin breakdown, and demoralization, as well as the fact that physical restraints do not decrease behavioral disturbances.6
Studies from the 1970s and 1980s indicated that between 20% and 50% of nursing home residents were receiving psychotropic medications.7-12 Unfortunately, there was little concern for documenting residents’ psychiatric diagnoses, recording results of mental status examinations, and obtaining psychiatric consultation. Specific concern was expressed that neuroleptic medications were being used as a form of chemical restraint, without consideration of less burdensome and risky forms of treatment, such as alternative classes of drugs or behavioral interventions. Moreover, once treatment with a neuroleptic medication was started, patients frequently continued the regimen long term, without any clear indication or attempts to taper the dosage or discontinue use once acute symptoms were stable.
1. Kaufer DI, Cummings JL, Christine D, et al. Assessing the impact of neuropsychiatric symptoms in Alzheimer’s disease: the Neuropsychiatric Inventory Caregiver Distress Scale. J Am Geriatr Soc. 1998;46:210-215.
2. Fuh JL, Liu CK, Mega MS, et al. Behavioral disorders and caregivers’ reaction in Taiwanese patients with Alzheimer’s disease. Int Psychogeriatr. 2001;13:121-128.
3. Donaldson C, Tarrier N, Burns A. Determinants of carer stress in Alzheimer’s disease. Int J Geriatr Psychiatry. 1998;13:248-256.
4. Cuijpers P. Depressive disorders in caregivers of dementia patients: a systematic review. Aging Ment Health. 2005;9:325-330.
5. Wilson RS, Tang Y, Aggarwal NT, et al. Hallucinations, cognitive decline, and death in Alzheimer’s disease. Neuroepidemiology. 2006;26:68-75.
6. The National Nursing Home Survey. Hyattsville, MD: US Dept of Health, Education, and Welfare, National Center for Health Statistics; July 1979. DHEW publication PHS 79-1794.
7. Avorn J, Dreyer P, Connelly K, Soumerai SB. Use of psychoactive medication and the quality of care in rest homes. Findings and policy implications of a statewide study. N Engl J Med. 1989;320:227-232.
8. Beers M, Avorn J, Soumerai SB, et al. Psychoactive medication use in intermediate-care facility residents. JAMA. 1988;260:3016-3020.
9. Burns EM, Buckwalter KC. Pathophysiology and etiology of Alzheimer’s disease. Nurs Clin North Am. 1988;23:11-29.
10. Cohen-Mansfield J. Agitated behaviors in the elderly. II. Preliminary results in the cognitively deteriorated. J Am Geriatr Soc. 1986;34:722-727.
11. Teeter RB, Garetz FK, Miller WR, Heiland WF. Psychiatric disturbances of aged patients in skilled nursing homes. Am J Psychiatry. 1976;133:1430-1434.
12. Zimmer JG, Watson N, Treat A. Behavioral problems among patients in skilled nursing facilities. Am J Public Health. 1984;74:1118-1121.
13. Health Care Financing Administration. Medicare and Medicaid: requirements for long-term care facilities, final regulations. Federal Register. September 26, 1991;56:48865-48921.
14. Health Care Financing Administration. Medicare and Medicaid programs: preadmission screening and annual resident review. Federal Register. November 30, 1992;57:56450-56504.
15. Health Care Financing Administration. Medicare and Medicaid: resident assessment in long-term care facilities. Federal Register. December 28, 1992;57:61614-61733.
16. Shorr RI, Fought RL, Ray WA. Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations. JAMA. 1994;271:358-362.
17. Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14:191-210.
18. Maher AR, Maglione M, Bagley S, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis [published correction appears in JAMA. 2012;307:147]. JAMA. 2011;306:1359-1369.
19. Kindermann SS, Dolder CR, Bailey A, et al. Pharmacological treatment of psychosis and agitation in elderly patients with dementia: four decades of experience. Drugs Aging. 2002;19:257-276.
20. Sultzer DL, Davis SM, Tariot PN, et al; CATIE-AD Study Group. Clinical symptom responses to atypical antipsychotic medications in Alzheimer’s disease: phase 1 outcomes from the CATIE-AD effectiveness trial. Am J Psychiatry. 2008;165:844-854.
21. Chan WC, Lam LC, Choy CN, et al. A double-blind randomised comparison of risperidone and haloperidol in the treatment of behavioural and psychological symptoms in Chinese dementia patients. Int J Geriatr Psychiatry. 2001;16:1156-1162.
22. De Deyn PP, Rabheru K, Rasmussen A, et al. A randomized trial of risperidone, placebo, and haloperidol for behavioral symptoms of dementia. Neurology. 1999;53:946-955.
23. Tariot PN, Schneider L, Katz IR, et al. Quetiapine treatment of psychosis associated with dementia: a double-blind, randomized, placebo-controlled clinical trial [published correction appears in Am J Geriatr Psychiatry. 2006;14:988]. Am J Geriatr Psychiatry. 2006;14:767-776.
24. Suh GH, Son HG, Ju YS, et al. A randomized, double-blind, crossover comparison of risperidone and haloperidol in Korean dementia patients with behavioral disturbances. Am J Geriatr Psychiatry. 2004;12:509-516.
25. Leon C, Gerretsen P, Uchida H, et al. Sensitivity to antipsychotic drugs in older adults. Curr Psychiatry Rep. 2010;12:28-33.
26. Mittal V, Kurup L, Williamson D, et al. Risk of cerebrovascular adverse events and death in elderly patients with dementia when treated with antipsychotic medications: a literature review of evidence. Am J Alzheimers Dis Other Demen. 2011;26:10-28.
27. Kim Y, Wilkins KM, Tampi RR. Use of gabapentin in the treatment of behavioural and psychological symptoms of dementia: a review of the evidence. Drugs Aging. 2008;25:187-196.
28. De León OA. Treatment of psychotic symptoms with lamotrigine in Alzheimer disease. J Clin Psychopharmacol. 2004;24:232-233.
29. Tariot PN, Raman R, Jakimovich L, et al; Alzheimer’s Disease Cooperative Study; Valproate Nursing Home Study Group. Divalproex sodium in nursing home residents with possible or probable Alzheimer Disease complicated by agitation: a randomized, controlled trial. Am J Geriatr Psychiatry. 2005;13:942-949.
30. Cummings JL, Mackell J, Kaufer D. Behavioral effects of current Alzheimer’s disease treatments: a descriptive review. Alzheimers Dement. 2008;4:49-60.