Forgetfulness, memory impairment and difficulty with self-care are a major challenge for people living with dementia. But the neuropsychiatric symptoms of dementia can cause the most distress for patients and their caregivers.
Common neuropsychiatric symptoms include behavioral issues such as aggression, agitation and wandering. Mood, psychotic and sleep-related disturbances are also very common. Usually, patients have a combination of symptoms making it very challenging to know how to intervene.
A family who wants to care for a beloved parent at home can become demoralized and burned out when their loved-one is combative, awake all night or prone to wandering. Experienced caregivers in elderly care settings can struggle with keeping patients safe when they are distressed, pacing and paranoid of staff.
In the past, providers routinely prescribed antipsychotic medications to manage even mild symptoms. Today’s providers try to use these medications sparingly, informed by the current FDA warnings about the risks of use of these medications in the elderly. Without medications, providers might feel they have little to offer patients and families in these situations. But in many cases, significant improvements in symptoms and quality of life can be made for these patients without a prescription.
So, how do you best approach your patient with concerning neuropsychotric symptoms?
First, assess the situation: Is there a risk of harm to self or others? If so, ensure safety first by considering increasing the level of care through the addition of caregivers, one-on-one supervision, or hospitalization. In cases with the risk of severe harm, short-term pharmacologic treatment will likely be indicated along with hospitalization.
More commonly, the risk level is lower. In these cases, thinking through a few key areas can have a major positive impact:
1. Identify and treat the underlying cause. Most often, these symptoms do not occur in a vacuum. Pain, distress and underlying illness can be a driver, and one that when properly identified can be alleviated. Below is a list of commonly found underlying causes:
- Delirium: assess for untreated medical illnesses, new medications, metabolic issues.
- Medication side effects: have a high suspicion for this with the prescribing of benzodiazepines, anticholinergics and opioids.
- Pain: a patient with major neurocognitive disorder may not be able to tell you they are in pain, so look at other clues such as body language and facial expression. Scheduled instead of as-needed non-narcotic pain medications can be helpful.
- Depression and anxiety: assess for this with the help of the caregiver. Consider a trial of an SSRI.
- Sleep disorders: sleep-wake disturbance is common in dementia. Emphasize good sleep hygiene, exposure to morning light, consistent schedule.
- Sensory deficits: Poor vision and hearing can worsen confusion and lead to agitation as well as worsened fall risk.
2. At times, simple interventions can go a long way:
- Implement daily, scheduled activities. Instruct families and caregivers to find activities that are soothing to the patient. Some patients will spend hours sorting through pictures, rearranging a silverware drawer or sweeping. Empower families and caregivers to get creative and try a variety of different strategies.
- Environmental interventions such as reducing clutter, improving lighting and adding soothing features such as music or pets can help.
As a provider, helping a family discover that their mom loves to arrange silverware, can do so for hours and is able to remain calm and content throughout the day can be satisfying and bring a sense of relief in not having to add a new medication to an elderly person’s already long list. As a prescriber working with geriatric patients, less is always more when it comes to medications.
Amanda Focht, MD
Clinical Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Medical Director, University of Washington Medical Center, Outpatient Psychiatry Clinic
Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA 2012; 308:2020.
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; 157:708.
Gitlin LN, Winter L, Dennis MP, et al. Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention. J Am Geriatr Soc 2010; 58:1465.