Rajesh R. Tampi, MD, MS, DFAPA

The population of older adults with substance use disorders (SUDs) is increasing in the United States.

 It has been postulated that by the end of 2020 there will be approximately 5.7 million older adults with SUDs when compared with 2.8 million individuals in 20062;the number of emergency department visits for drug misuse on an average day for older patients can be seen in 

. Older adults tend to preferentially abuse alcohol, nicotine, and prescription medications while younger individuals use marijuana, cocaine, and heroin.

 There is a considerable scarcity of data regarding SUDs among older adults despite concerns of this issue being a major public health concern.

Older adults are considered an at-risk population for using psychoactive drugs, as aging is 

associated with an increased burden of health-related issues and psychosocial stressors that can increase the risks due to use of psychoactive drugs.

 It is estimated that at least 1 in 4 older adults has used psychoactive medications within a pattern of substance abuse.

 indicated that approximately 43% of individuals aged 65 years or older admitted to using alcohol in the past year with approximately 6.7% of these individuals reporting a pattern of alcohol abuse or dependence symptoms.

 The 2008-2009 US National Surveys on Drug Use and Health indicated that 14.1% of individuals aged 65 years or older reported past-year tobacco use when compared with 30.2% individuals aged 50 to 64 years.

2005 and 2006 National Surveys on Drug Use and Health

 found that among adults aged 65 years or older, 0.7% had used marijuana and 0.04% had used cocaine in the past year.

 The rates of past-year use of inhalants, hallucinogens, methamphetamine, and heroin were also low at less than 0.2%.

Among individuals aged 50 years or older, the past-year non-medical use of prescription opioids at 1.4% is more prevalent than the non-medical use of prescription sedatives (0.14%), tranquilizers (0.46%), and stimulants (0.16%).

 In this age group, the past-year prevalence of prescription opioid use disorders was low at 0.13%, but the risk of prescription opioid dependence was higher at 7.6%. Of concern is that in the US, 8.7% of individuals aged 65 to 80 years filled at least one prescription for benzodiazepines in a 1-year period with 31.4% of these individuals receiving benzodiazepines for longer than 120 days in a year.

 These data suggest a population at increased risk for SUDs and associated comorbidities.

Risk factors for the development of SUDs among older adults include a history of substance use, comorbid psychiatric disorders, and the presence of cognitive impairment.

 Factors that mitigate the development of SUDs include being married, no previous history of substance use, and a religious affiliation. SUDs are moderately to highly heritable; findings indicate that an individual’s risk would be proportional to the degree of genetic relationship to the relative with SUDs. For reference, the heritability rates for hallucinogen use disorder is 0.39 and for cocaine use disorder is 0.72.

SUDs among older adults is associated with worse medical outcomes and increased economic burden of care. The long-term use of psychoactive substances can result in adverse neurological outcomes even at therapeutic doses. These adverse effects include drowsiness, confusion, slowed psychomotor functioning, impaired reaction time, incoordination, ataxia, falls, and amnesia. The sustained use of psychoactive drugs often results in the development of physiological and physical dependence. Abrupt discontinuation of these drugs may result in serious withdrawal symptoms including delirium and seizures. The use of these substances may also result in problematic drug interactions with other prescribed medications or over-the-counter medical products.

Chronic use of psychoactive drugs can result in multiple medical complications including cardiac, hepatic, and renal impairments leading to greater rates of disability, morbidity and mortality. Approximately one-fifth of older adults who are hospitalized due to psychiatric disorders have a comorbid substance use disorder. 

 have higher rates of depression and suicide than age matched controls. The overall economic burden of substance use disorders among older adults is higher owing to greater risks for and rates of comorbidities, longer inpatient hospital stays and also the subsequent greater need for more intense outpatient programs to manage symptoms when compared with age matched controls.

Available evidence indicates that SUDs among older adults are often underdiagnosed and poorly treated.10 The reasons for this underdiagnosis and poor treatment include lack of awareness regarding these disorders, denial of the disorder, the shame and stigma of using addictive substances, reluctance to seek professional help, lack of financial resources, the lack of social supports, the presence of comorbid conditions, limited time spent with primary care physicians, and the ageist attitudes toward mental health disorders among older individuals.

The use of standard diagnostic criteria (eg, DSM-5), which are validated for use among younger adults tends to underestimate the prevalence of SUDs when among older adults. The 

Consensus Panel of the Treatment Improvement Protocol 

(TIP) recommends screening for alcohol and prescription drug use disorders as part of a regular physical examination among adults aged 60 years or older.11 The routine use of standardized screening instruments like the Michigan Alcohol Screening Test-Geriatric (MAST-G), the CAGE screening test, and computerized screening tools like the Drug and Alcohol Problem Assessment for Primary Care (DAPA-PC) can assist with the appropriate diagnosis of SUDs among older adults.

Available evidence indicates that treatments for SUDs among older adults are as successful as treatments for substance use disorders among younger adults.10 Programs that improve outcomes among older adults with SUDs include those that emphasize age-specific treatments, use of supportive and non-confrontational approaches that build self-esteem, emphasize cognitive-behavioral approaches, assist in development of skills to improve social support, use counselors who are trained and motivated to work with older adults and use of age-appropriate pace and content.

 Additionally, older adults have better outcomes when they are enrolled in programs where there is close monitoring for drug interactions and adverse effects of medication treatments.

 This is especially true among individuals withdrawing from alcohol and other drugs in which the withdrawal symptoms may be severe and prolonged.

are approved by the US Food and Drug Administration for the treatment of alcohol use disorder and buprenorphine is approved for the treatment of opiate use disorder among adults.

 However, the data on the use of these medications for the treatment of SUDs among older adults is limited. A review of the literature indicates that there are only two randomized controlled trials (RCTs) that evaluated the use of pharmacologic agents for SUDs among older adults. One trial evaluated the use of naltrexone when compared with placebo for the treatment of alcohol use disorder among individuals who were aged 50 to 70 years. The other trial evaluated the use of naltrexone or placebo as adjuncts with sertraline in the treatment of alcohol use disorder among individuals aged 55 years or older. Both trials showed that the use of naltrexone reduced the rates of relapse among older adults with alcohol use disorder. There are no RCTs that evaluated the use of buprenorphine, acamprosate, or disulfiram for SUDs among older adults. 

 illustrates the 5 steps that can ensure success in the treatment of substance use disorders among older adults.

The number of older adults with an SUD will increase appreciably in the near future. The currently available diagnostic criteria that have been developed to identify SUDs among younger individuals are less sensitive in identifying SUDs among older adults. The use of standardized screening tools and specific diagnostic criteria will improve the identification of older individuals with SUDs.

Older adults with SUDs respond well to treatments, if these programs are specifically designed to meet the needs of the older adult population. However, additional studies are needed because there is a dearth of evidence regarding pharmacotherapy for SUDs among older adults.

 is Chairman, Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH; Chief, Section for Geriatric Psychiatry, Cleveland Clinic, Cleveland, OH; and Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.

 is Executive Vice President, Diamond Healthcare, Richmond, VA. 

Department of Psychiatry & Behavioral Sciences; and Medical Director, Alcohol & Drug Recovery Center, Cleveland Clinic Akron General, Akron, OH

The authors report no conflicts of interest concerning the subject matter of this article.

This article originally appeared online on July 9, 2020 under the title, "Substance Use Disorders Among Older Adults: Five Steps to Improve Outcomes," and has since been updated. -Ed.

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Articles

Addiction among older adults is associated with worse medical outcomes and increased economic burden of care. The long-term use of psychoactive substances can result in adverse neurological outcomes even at therapeutic doses. 

5 Steps to Improve Outcomes in Substance Abuse in Older Patients

Available data indicate that anxiety disorders are the most prevalent of psychiatric disorders among older adults.

 The National Comorbidity Survey Replication (NCS-R) found that among individuals aged 60 years or older, the prevalence of any anxiety disorder was 15.3% with specific phobia being the most prevalent: 7.5%; followed by social phobia: 6.6%; generalized anxiety disorder (GAD): 3.6%; PTSD: 2.5%; panic disorder: 2%; agoraphobia without panic: 1%; and OCD: 0.7% (

The risk factors for anxiety among older adults can be divided into external and internal factors. The external factors (ie, stress factors) include chronic medical illnesses, disability, and major illness in a spouse; internal factors (ie, vulnerability factors) include personality traits of neuroticism and low self-efficacy.

Among older adults, anxiety disorders are associated with reduced physical activity and functional status, poorer self-perceptions of health, decreased life satisfaction, increased loneliness, decreased quality of life, increased service use, and the overall greater cost of care. Anxiety disorders are also a 

Despite their prevalence, anxiety disorders among older adults are under-recognized and poorly treated. Among older adults, primary care physicians correctly made the diagnosis of any anxiety disorder in approximately 9% of the older adults.

 The most common reason for poor recognition the physical symptoms associated with anxiety disorders (eg, sleep disturbances, fatigue, restlessness, difficulty concentrating) tend to overlap with medical disorders commonly seen among older adults. Current diagnostic criteria for anxiety disorders were developed for use in younger individuals and are not sensitive to detecting these disorders in older adults, which further complicates recognition. And, these disorders often co-occur with depression, substance use disorders, and cognitive disorders among older adults, which makes the correct diagnosis more complex.

The initial step in evaluating older adults who present with symptoms of an anxiety disorder is to get a thorough history. Because anxiety disorders in older adults are highly comorbid with cognitive disorders, information from a collateral source is essential to clarify the history of symptoms. Eliciting history is often followed by a mental status examination and formal cognitive testing.

The next step is to assess for comorbid disorders (eg, depression, psychosis, cognitive dysfunction) and treat them. A focused physical examination and laboratory testing should also be completed to rule out co-occurring medical illness and adverse effects of prescribed drugs or drugs of abuse.

Although not specifically developed for use among older adults, standardized rating scales help with qualifying and quantifying the symptoms of anxiety. These rating scales can be divided into self-report scales and clinician-rated scales. The commonly available self-reported scales include the Worry Scale (WS), the State-Trait Anxiety Inventory (STAI), the Penn State Worry Questionnaire (PSWQ), Padua Inventory (PI), and the Beck Anxiety Inventory (BAI).

 Clinician-rated scales include the Structured Clinical Interview for DSM (SCID), the Diagnostic Interview Schedule (DIS), the Anxiety Disorders Interview Schedule (ADIS-R), and the Hamilton Anxiety Rating Scale (HARS). In cases in which anxiety disorders are comorbid with other psychiatric disorders including mood disorders, psychotic disorders, personality disorders, and/or 

, neuropsychological testing may be very useful in making the appropriate diagnoses and developing subsequent treatment plans.

Findings indicate that a stepped-care program reduces the 12-month and 24-month incidence of depressive and anxiety disorders by one-half of the usual care, and it is cost-effective.

 With this care model, older individuals sequentially receive a watchful waiting approach, cognitive behavioral therapy (CBT)-based bibliotherapy, cognitive behavioral therapy-based problem-solving treatment, and a referral to a primary care clinician for medication management as needed.

A meta-analysis of non-pharmacological interventions for late-life anxiety in 495 patients found that psychological interventions were more effective than no treatment on both self-rated and clinician-rated measures of anxiety with an effect size of 0.55.

 A meta-analysis that evaluated the efficacy of CBT alone, CBT with relaxation training, and relaxation training alone for late-life anxiety found that treatments were more effective than active control conditions.

 The researchers also found that CBT (alone or augmented with relaxation training) did not seem to add anything beyond relaxation training alone.

Data from 10 randomized controlled trials (RCTs) of antidepressants for late-life anxiety demonstrated that antidepressant use was associated with a significant reduction in anxiety symptoms at the end of the study period, but the trials predominantly included patients with generalized anxiety disorder (GAD) and there were limited data regarding the long-term use of antidepressants for anxiety.

In a soon to be published systematic review, Gupta and colleagues

 identified 5 RCTs that used benzodiazepines for treatment of anxiety disorders among older adults. They found that benzodiazepine use was associated with decreased anxiety at the end of each study period. Tolerability data showed mild adverse effects from the use of benzodiazepines. The main short comings of the study were limited data on the long-term use of benzodiazepines for anxiety and that the majority of the trials evaluated the use of benzodiazepines for GAD. Benzodiazepines should be used cautiously among older adults given their significant adverse effect profile including dependence, 

 sequenced treatment with pharmacotherapy and CBT for patients with GAD who were aged 60 or older. These individuals initially received 12 weeks of open-label escitalopram treatment. The researchers found that patients who received escitalopram augmented with CBT had improved response rates on the Penn State Worry Questionnaire compared with patients who received escitalopram alone. They also found that both escitalopram and CBT prevented relapse compared with placebo.

Anxiety disorders are not uncommon among older adults, but they are often underdiagnosed or misdiagnosed. And, they are associated with significant comorbidity and mortality among older patients. The development of specific diagnostic criteria that are applicable to older adults can aid in the accurate diagnosis of these disorders in late life. Psychotherapy that includes relaxation training and pharmacotherapy have been found efficacious for anxiety disorders among older adults.

 is Chairman, Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH; Chief, Section for Geriatric Psychiatry, Cleveland Clinic, Cleveland, OH; and Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH. 

 is Executive Vice President, Diamond Healthcare, Richmond, VA. The authors report no conflicts of interest concerning the subject matter of this article.

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2. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. 

3. Becker E, Orellana Rios CL, Lahmann C, et al. 

Anxiety as a risk factor of Alzheimer’s disease and vascular dementia

4. Calleo J, Stanley MA, Greisinger A, et al. Generalized anxiety disorder in older medical patients: diagnostic recognition, mental health management and service utilization. 

5. Tampi RR, Tampi DJ. Anxiety disorders in late life: a comprehensive review. 

6. Nordhus IH, Pallesen S. Psychological treatment of late-life anxiety: an empirical review. 

7. Thorp SR, Ayers CR, Nuevo R, et al. Meta-analysis comparing different behavioral treatments for late-life anxiety. 

8. Balasubramaniam M, Joshi P, Alag P, et al. Antidepressants for anxiety disorders in late-life: a systematic review. 

9. Gupta A, Bhattacharya G, Farheen SA, et al. Systematic review of benzodiazepines for anxiety disorders in late life. 

10. Markota M, Rummans TA, Bostwick JM, Lapid MI. Benzodiazepine use in older adults: dangers, management, and alternative therapies. 

11. Wetherell JL, Petkus AJ, White KS, et al. 

Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults

The development of specific diagnostic criteria that are applicable to older adults can aid in the accurate diagnosis of psychiatric disorders in late life. 

The Most Prevalent Psychiatric Disorder in Older Adults

Rajesh R. Tampi, MD, MS, DFAPA, provides guidance for frontline health professionals and caregivers to mitigate stress and burden.

Dr Tampi is Chairman, Department of Psychiatry and Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, and Chief, Section of Geriatric Psychiatry, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH

COVID-19: Quick Self-Check for Health Professionals

 neurodegenerative disorder in the US after Alzheimer disease (AD).

 It is estimated that in the US alone approximately 630,000 individuals have a diagnosis of PD. The prevalence of PD increases with age and it is estimated that the prevalence will double by 2040.

 The disorder is significantly more common among individuals aged 80 years or older compared with those aged 40 to 49 years (1903 per 100,000 population versus 41 per 100,000 population, respectively). The overall cost of caring for individuals with PD is approximately $52 billion per year.

Although not one of the cardinal features of PD, psychotic symptoms are seen in approximately 25% to 30% of individuals with PD.

 The risk factors for the development of psychotic symptoms in PD (ie, PD psychosis) include older age, greater severity of illness, longer duration of illness, the axial rigidity subtype of PD, idiopathic PD, underlying dementia, delirium or depression, the presence of sleep disturbance including REM behavior disorder, reduced vision, and the use of dopaminergic agents (

 PD psychosis is also associated with worsening quality of life, greater caregiver distress, higher rates of institutionalization, increased mortality, and greater health care costs.

Among individuals with PD, visual hallucinations are the most prevalent psychotic symptom (

 Visual hallucinations are seen in approximately one-quarter to one-third of individuals with PD, with a lifetime prevalence of about 50%.

 Auditory hallucinations occur in approximately 20% of individuals with PD. Certain minor phenomena such as the “sense of presence” and visual illusions can be seen among 17% to 72% of individuals with PD and these may progress to visual hallucinations as the illness progresses. Delusions are not very common with a prevalence of approximately 5%.

National Institute of Neurological Disorders and Stroke

 (NIMH) has proposed the following for the diagnosis of PD psychosis:

â¼ The presence of one or more of the following symptoms: illusions, false sense of presence, hallucinations, or delusion;

â¼ The UK brain bank criteria for the diagnosis of PD is met;

â¼ The symptoms occurred after the diagnosis of PD;

â¼ The symptoms are recurrent or continuous for 1 month;

â¼ The symptoms are not better accounted for by another cause of Parkinsonism (eg, dementia with Lewy bodies; psychiatric disorders such as schizophrenia, schizoaffective disorder; delusional disorder or mood disorder with psychotic features; a general medical condition including delirium);

â¼ PD psychosis could be associated with or without insight, with or without dementia, and with or without treatment for PD.

The exact pathophysiology of PD psychosis is unclear, but findings indicate that the cholecystokinin gene (CCK)-45C-T polymorphism is most often associated with PD psychosis.

 Moreover, alterations in the visual processing areas in the brain along with pathologies in the hippocampus and cholinergic brain structures are seen among individuals with PD psychosis. Frontal cognitive dysfunction, impaired visual processing, sleep-wake cycle dysregulation and brainstem dysfunction all contribute to the development of PD psychosis.

When assessing patients, a thorough history assists in identifying risk and precipitating factors for PD psychosis.

 Precipitating factors include medical conditions such as dehydration, infections, metabolic dysfunction; psychosocial factors include poor sleep and limited nutrition; psychological factors include stress and hospital admissions as well as the use of drugs like amantadine, anticholinergic drugs, dopaminergic drugs, and beta-blockers.

The Movement Disorder Society Task Force that evaluated the rating scales for assessing PD psychosis 

that none of the currently available scales adequately captured its entire phenomenology.

 They recommend that the following be used as primary scales in clinical trials evaluating new treatments for patients with PD psychosis: the Neuropsychiatric Inventory (NPI) for the cognitively impaired population or when a caregiver is required; Schedule for Assessment of Positive Symptoms (SAPS), Positive and Negative Syndrome Scale (PANSS) or the Brief Psychiatric Rating Scale (BPRS) for the cognitively intact population or when the patient is the sole informant. The Clinical Global Impression Scale (CGIS) was suggested as a secondary outcome scale to measure change and response to treatment over time (See 

The first step in the management of PD psychosis is to assess the severity of symptoms. For mild symptoms that are not bothersome, there is no need for specific intervention other than providing reassurance and close monitoring to evaluate the progression of symptoms. The next step is to identify and treat for secondary causes of PD psychosis including medical disorders.

Medications that are used to treat the motor symptoms of PD may cause or worsen psychosis.

 A reduction or discontinuation of anticholinergics, monoamine oxidase inhibitors, levo- dopa, or dopamine agonists may result in the improvement of symptoms.

 If discontinuation of these agents is ineffective, psychotropic medications, may be indicated.

A systematic review of placebo-controlled trials by Wilby and colleagues

 demonstrated benefit for clozapine and pimavanserin for the treatment of PD psychosis. There were no definitive benefits noted for either quetiapine or olanzapine. The comparative studies showed improvements in PD psychosis symptoms when clozapine or comparator drug were assessed alone, but the data did not suggest any superiority of one active drug over the other drugs.

Pimavanserin, a novel 5-HT2A inverse agonist is the first FDA-approved antipsychotic for the treatment of hallucinations and delusions associated with PD psychosis.

 Pimavanserin improves symptoms of PD psychosis when compared with placebo (P = .0014). The adverse effect profile of pimavanserin include urinary tract infections, falls, peripheral edema, hallucinations, confusion, nausea, and headaches. Electroconvulsive therapy (ECT) has also been found to be beneficial for refractory symptoms.

Psychotic symptoms are not uncommon among patients with PD, and psychosis is associated with worse outcomes. Risk factors for PD psychosis include advancing age, more severe disease stage, cognitive impairments, depression, and sleep disorders.

The pathogenesis of PD psychosis involves neuropathological, neurochemical, and genetic changes. Management of PD psychosis involves treatment of underlying medical disorders and discontinuing drugs that may precipitate or worsen symptoms. Findings also indicate efficacy for clozapine and pimavanserin for the treatment of symptoms of PD psychosis. Pimavanserin remains the only FDA-approved medication for the treatment of PD psychosis. ECT may be beneficial for refractory PD psychosis symptoms.

 is Chairman, Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, and Chief, Section of Geriatric Psychiatry, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; 

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10. Lenka A, Herath P, Christopher R, et al. Psychosis in Parkinson disease: from the soft signs to the hard science. 

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12. Ravina B, Marder K, Fernandez HH, et al for the NIMH work group. Diagnostic criteria for psychosis in Parkinson disease: report of an NINDS. 

13. Gallagher DA, Parkkinen L, O’Sullivan SS, et al. Testing an aetiological model of visual hallucinations in Parkinson disease. 

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	17. Patel T, Chang F, for the Parkinson Society Canada. Parkinson disease guidelines for pharmacists. 

18. Wilby KJ, Johnson EG, Johnson HE, Ensom MHH. Evidence-based review of pharmacotherapy used for Parkinson disease psychosis. 

19. Bozymski KM, Lowe DK, Pasternak KM, et al. Pimavanserin: a novel antipsychotic for Parkinson disease psychosis. 

20. Ueda S, Koyama K, Okubo Y. Marked improvement of psychotic symptoms after electroconvulsive therapy in Parkinson disease. 

Parkinson disease psychosis is associated with worsening quality of life, greater caregiver distress, higher rates of institutionalization, increased mortality, and greater health care costs. The authors explore medical, psychosocial, and psychological factors associated with PD psychosis.

Parkinson Disease Psychosis

Alzheimer disease and other dementias are a major and increasing global health challenge. In 2010 there were 35.6 million individuals living with dementia and their numbers are expected to double every 20 years and reach approximately 115.4 million by 2050.

Behavioral and psychological symptoms of dementia (BPSD) is used to describe a group of diverse non-cognitive symptoms and behaviors that are frequently seen among individuals with dementia. BPSD affects approximately 90% of individuals at some point during the course of the illness, with greater prevalence noted among individuals receiving skilled care.

Common BPSD include apathy, anxiety, depression, agitation, psychosis, sleep disturbances, dysphoria, aberrant motor activity, hallucinations and delusions. There is emerging evidence that specific symptom patterns can be identified in different types of dementias. One recent study found that hallucination, abnormal motor behavior, and anxiety were significantly more frequent in Alzheimer disease (AD) and mixed dementia (MD) compared with vascular dementia (VD).

 Hallucinations and delusions were significantly more severe in AD and MD . Disinhibition was significantly more frequent and severe and agitation was significantly more severe in patients with VD.

BPSD is associated with faster cognitive decline, greater functional impairment, reduced quality of life for patients and their caregivers. BPSD is also a risk factor for earlier institutionalization among individuals with dementia. Moreover, BPSD adds to the overall cost of caring for individuals with dementia.

This spectrum of symptoms is thought to occur due to the complex interaction between biological, psychological, social, and environmental factors. These factors include structural, functional, and neurochemical changes in the brain, underlying medical or psychiatric disorders, preexisting personality traits, caregiver distress/depression, and misleading or lack of stimuli from the environment.

When an individual is being assessed for BPSD, it is vitally important to collect information from the caregivers of these individuals. Collateral information will provide insight into the type and duration of symptoms, aggravating and mitigating factors, prognostic factors, and a history of interventions that have been beneficial in managing BPSD. Underlying medical and psychiatric conditions should be evaluated and appropriately managed as these might be precipitating and/or worsening the BPSD. A thorough medication review will help eliminate the effect of medications, which may cause and/or aggravate the BPSD. This is also true of any illicit substances.

An assessment of BPSD includes the use of standardized and validated assessment scales such as the Neuropsychiatry Inventory (NPI) or the Behavioral Pathology in Alzheimer Disease Rating Scale (BEHAVE-AD). These standardized tools can assist in qualifying and quantifying the BPSD. They can also assist with tracking the progression of BPSD and the efficacy of interventions.

Both nonpharmacological and pharmacological management strategies have been found to be beneficial among individuals with BPSD. Among the nonpharmacological strategies, music therapy and behavioral management techniques appear to be effective for reducing the BPSD.

 These interventions have been shown to reduce the frequency and severity of the BPSD and also decrease caregiver burden with effect sizes similar to those of associated with pharmacotherapy.

To be successful nonpharmacological interventions need to be individualized and delivered in a caring way in a caring environment.

 Nonpharmacological interventions that targets both the patient and the provider improves the lives of both partners in the dyad.

Nonpharmacological management strategies are often used prior to or in conjunction with pharmacotherapy. This is done to minimize the exposure of individuals with BPSD to pharmacotherapeutic agents, given their significant adverse effect profile.

Although there are no FDA-approved medication classes to manage BPSD, many medications have been tested.

 Common medication classes that have been used in the management of BPSD include antidepressants, antipsychotics, anticonvulsants ,and cholinesterase inhibitors.

Findings from a meta-analysis indicates that only two medications had statistically significant higher response rates than placebo in the management of BPSD: dextromethorphan/quinidine [odds ratio (OR) = 3.04] and risperidone (OR =1.88) respectively.

 Dextromethorphan/quinidine and risperidone were also found to be superior to haloperidol and quetiapine. Haloperidol failed to demonstrate higher efficacy than placebo (OR = 0.86), and it was less efficacious compared with nearly all medications in the network. No individual SSRI was found to have significantly greater efficacy than placebo. There were non-significant differences in treatment acceptability for nearly all medications when compared with placebo, except for oxcarbazepine (OR = 3.73). Oxcarbazepine also had inferior acceptability when compared with donepezil and haloperidol.

Data from a second meta-analysis show that compared with placebo, aripiprazole, quetiapine, and risperidone were associated with improvements in symptoms on different standardized rating scales (

 However, the differences between the atypical antipsychotics were not significant for effectiveness, death, or cerebrovascular events. Compared with placebo, risperidone (OR = 3.85) and olanzapine (OR = 4.28) were associated with increased risk for cerebrovascular events.

A multidisciplinary team from Canada created an evidence-based algorithm for the management of BPSD.

 After a baseline assessment and the discontinuation of potentially exacerbating medications they recommend sequential trials using risperidone, aripiprazole or quetiapine, carbamazepine, citalopram, gabapentin, and prazosin, if pharmacotherapy is indicated.

A recent expert panel consensus recommended a step-wise approach to the management of BPSD.

 The panel recommendation is that management commence with the identification of underlying causes for BPSD. This should be followed by the implementation of nonpharmacological management strategies including caregiver training, environmental adaptations, person-centered care, and tailored activities. If pharmacologic interventions are required, the use of citalopram and analgesia should be given priority before other medication classes especially antipsychotics. For the management of psychosis, risperidone could be used after the evaluation and management of underlying causes for the psychosis.

In addition, emerging data indicate the efficacy of cannabinoid and electroconvulsive therapy (ECT) for the management of BPSD.

 Other treatments that are being studied include pimavanserin, lithium, gabapentin, mirtazapine, escitalopram, carbamazepine, and methylphenidate.

BPSD is associated with worse outcomes for patients with dementia. The management of patients is not standardized, but protocols generally involve the treatment of underlying symptoms followed by the use of nonpharmacological management techniques and evidence-based pharmacotherapy for refractory BPSD. When using antipsychotic medications, caution is advised given their significant adverse effect profile. Treatment outcomes among individuals with BPSD can be improved by using a risk to benefit analysis and step-wise approach to management.

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3. Majer R, Simon V, Csiba L, et al. Behavioural and psychological symptoms in neurocognitive disorders: specific patterns in dementia subtypes. 

4. Abraha I, Rimland JM, Trotta FM, et al. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. 

5. Brodaty H, Arasaratnam C. Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. 

6. Caspar S, Davis ED, Douziech A, Scott DR. Nonpharmacological management of behavioral and psychological symptoms of dementia: what works, in what circumstances, and why? 

7. Wang F, Feng TY, Yang S, et al. Drug therapy for behavioral and psychological symptoms of dementia. 

8. Kongpakwattana K, Sawangjit R, Tawankanjanachot I, et al. Pharmacological treatments for alleviating agitation in dementia: a systematic review and network meta-analysis. 

9. Yunusa I, Alsumali A, Garba AE, et al. Assessment of reported comparative effectiveness and safety of atypical antipsychotics in the treatment of behavioral and psychological symptoms of dementia: a network meta-analysis. 

10. Davies SJ, Burhan AM, Kim D, et al. Sequential drug treatment algorithm for agitation and aggression in Alzheimer and mixed dementia. 

11. Kales HC, Lyketsos CG, Miller EM, Ballard C. Management of behavioral and psychological symptoms in people with Alzheimes disease: an international Delphi consensus. 

12. Tampi RR, Young JJ, Tampi DJ. Cannabinoids for the treatment of behavioral and psychological symptoms of dementia. 

13. Tampi RR, Tampi DJ, Young J, et al. The place for electroconvulsive therapy in the management of behavioral and psychological symptoms of dementia. 

14. Cummings J, Ritter A, Rothenberg K. Advances in management of neuropsychiatric syndromes in neurodegenerative diseases. 

15. Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. 

BPSD is associated with worse outcomes for patients with dementia. Management is not standardized, but protocols generally involve the treatment of underlying symptoms followed by the use of nonpharmacological management techniques and evidence-based pharmacotherapy for refractory BPSD.

Managing Behavioral and Psychological Symptoms of Dementia

Edited by Helen Lavretsky,
Martha Sajatovic, and Charles Reynolds III;
New York: Oxford University Press; 2016
592 pages • $125 (hardcover)

Books on complementary and integrative therapies are rare, especially those that pertain to mental health and aging. Thus, it was a pleasant surprise to see this volume published by 

 earlier this year. This book has been thoughtfully edited by 3 of the foremost experts in the treatment of geriatric mental health disorders: Drs. 

, and Charles Reynolds III. Together they bring to bear years of research and clinical and scholarly acumen into editing a resource for anyone who is interested in learning more about the evidence behind complementary, alternative, and integrative medicine for late-life mental health disorders.

The book is divided into 4 parts. The first 3 parts provide an overview of the biology of aging, disorders associated with aging, and various 

 therapies that can promote well-being and reduce stress. These sections include chapters on nutrition, herbal remedies, hormone therapy, massage therapy, chiropractic care, Ayurveda, homeopathy, yoga, and other approaches. In addition, there is a well-written chapter on resilience building and its benefits for successful and positive aging. The last section deals with integrative interventions of cognitive aging and mental disorders in late life.

All the chapters are written by experts who have stellar credentials. The well-referenced chapters are succinct, and the 2-column format of the pages makes them easy to read. In addition, excellent tables and figures highlight the data. Overall, the information is up to date and very user friendly.

The hardcover edition looks and feels like a real textbook. For those who prefer an electronic version, the publisher has made one available.

There is a paucity of information on complementary and integrative therapies, especially when they pertain to the topic of mental health and aging. But that's all changed.

Author | Rajesh R. Tampi, MD, MS, DFAPA

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