Aggression, agitation, and psychosis are common among patients with dementia. “When problematic behaviors arise, construct a differential diagnosis, as you would with any other problem in practice,” Dr. Rabins suggests. “They could [reflect] a medical condition, medication side effect, difficulties in the environment or relationship with a caregiver, or primary psychiatric symptoms like depression or hallucination.”
Except when danger to the patient or others is acute, nonpharmacologic interventions should be tried before medication. These might include such measures as reassurance and changes in the environment or patient care routines; such psychosocial interventions as art, music, or pet therapy; or supportive psychotherapy. According to the guideline authors, “Consideration and use of behavioral, psychosocial, and psychotherapeutic treatments is particularly critical given the large number and potential severity of side effects associated with pharmacotherapy.”
For drug treatment of agitation and behavioral difficulties, evidence indicates that antipsychotics are modestly effective. Such second-generation agents as olanzapine (Zyprexa) and risperidone (Risperdal) are most commonly used. The guideline notes that evidence for their efficacy beyond 12 weeks is limited, but “considerable clinical experience supports this practice.”
The risks associated with antipsychotics are substantial: these include cerebrovascular accidents, hyperlipidemia, weight gain, diabetes mellitus, and worsening cognition. In fact, second-generation antipsychotics bear a black-box warning for increased mortality in elder patients with dementia, “and recent data suggest that first-generation (typical) agents carry at least a similar risk,” the guideline authors write.
Benzodiazepines provide modest benefits that make them occasionally useful for treating anxiety or infrequent episodes of agitation or for sedation during a dental or medical procedure. Their prominent adverse effects (i.e., cognitive impairment, delirium, risk of falls, worsening breathing disorders) and concerns about dependence argue against their long-term use, however. Lorazepam (Ativan) and oxazepam (Serax), which have no active metabolites, are preferable to such longer-acting agents as diazepam (Valium).
Depression and sleep disturbances
Mood disorders are common among patients with dementia and have been shown to increase mortality and disability and worsen cognitive impairment.
Clinically significant and persistent depression requires pharmacotherapy. “It’s no different than in an older person without dementia,” affirms Dr. Rabins.
Safety and tolerability generally make selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors the drugs of choice. When circumstances permit, a low starting dose and very gradual increase will maximize the likelihood that the patient will be able to tolerate the antidepressant at a therapeutic dosage.
Up to half of patients with dementia experience some form of sleep problem. A number of contributing factors can be involved, and initial treatment should aim to improve sleep hygiene (e.g. set regular bed and waking times, limit daytime sleeping, avoid fluid consumption in the hours before sleep), address medical and psychiatric conditions (including pain) that may interfere with sleep, and adjust or replace medications that cause insomnia. Drugs with sedating side effects that have been already prescribed should be given at bedtime.
If these measures fail and medication is necessary, low-dose trazodone (Desyrel) at bedtime, and such nonbenzodiazepine hypnotics as zolpidem (Ambien) and zaleplon (Sonata), might be considered. Benzodiazepines are best avoided, as are OTC sleep aids with diphenhydramine, which has anticholinergic properties and may, paradoxically, worsen insomnia.
When to refer
“My assumption is that almost every patient with dementia should start out in primary care,” says Dr. Rabins. A specialist work-up is indicated, however, when the presentation is atypical: e.g. the patient is young (especially under age 60 years) or there are prominent noncognitive neurologic signs.
Under most circumstances, PCPs can manage behavioral difficulties and uncomplicated depression in the context of dementia, but if these don’t respond to standard interventions, a referral is probably in order.