neurologic disorders
Behavioral and Psychologic Symptoms of Dementia
Treatment
Environmental measures and caregiver support Medications only when necessary Management of behavioral and psychologic symptoms of dementia is controversial and has been inadequately studied. Supportive measures are preferred; however, medications are commonly used. The Environmental measures should be safe and flexible enough to accommodate behaviors that are not dangerous. Signs to help patients find their way and doors equipped with locks or alarms can help ensure the safety of patients who wander. Flexible sleeping hours and organization of beds can help patients with sleeping problems. Measures used to treat dementia generally also help minimize behavioral symptoms: Providing cues about time and place Explaining care before giving it Encouraging physical activity If an institution cannot provide an appropriate environment for a particular patient, transferring the patient to one that can provide a more appropriate environment may be preferable to using medications. Providing Caregiver assistance is crucial. Learning how dementia leads to behavioral and psychologic symptoms and how to respond to disruptive behavior can help family members and other caregivers provide care for and cope with the patient better. Learning how to manage stress, which may be considerable, is essential. Stressed caregivers should be referred to support services (eg, social workers, caregiver support groups, home health aides) and should be told how to obtain respite care if such care is available. Family members who are caregivers should be monitored for depression, which occurs in nearly half of them. Depression in caregivers should be treated promptly. Medications (eg, cholinesterase inhibitors) may also help manage behavioral and psychologic symptoms in patients with dementia. However, medications directed primarily at behavior (eg, antipsychotics) are used only when other approaches are ineffective and when these medications are essential for safety. The need for continued treatment should be reassessed at least every month. Medications should be selected to target the most intolerable behaviors. Medications for Treatment of Depression , preferably selective serotonin reuptake inhibitor ( Antipsychotic Drugs are often used even though their efficacy has been shown only in psychotic patients. Other patients are unlikely to benefit and are likely to experience adverse effects, particularly extrapyramidal symptoms. Tardive dyskinesia or tardive dystonia may develop; these conditions often do not resolve when the dose is reduced or the medication is stopped. Choice of antipsychotic depends on relative toxicity. Of conventional antipsychotics,haloperidolis relatively nonsedating and has less potent anticholinergic effects but is most likely to cause extrapyramidal symptoms;thioridazineandthiothixeneare less likely to cause extrapyramidal symptoms but are more sedating and have more anticholinergic effects thanhaloperidol. Second-generation (atypical) antipsychotics (eg,aripiprazole,olanzapine,quetiapine,risperidone) are minimally anticholinergic and cause fewer extrapyramidal symptoms than conventional antipsychotics; however, these medications, used for an extended period, may cause weight gain and hyperlipidemia and increase the risk of type 2 diabetes. In older patients with dementia-related psychosis, these medications may increase the risk of stroke and death. If antipsychotics are used, they should be given in a low dose (eg,olanzapine2.5 to 15 mg orally once a day;risperidone0.5 to 3 mg orally every 12 hours;haloperidol0.5 to 1.0 mg orally, IV, or IM twice a day or as needed) and for a short time. Choice of Drugs for Seizures , particularly valproate, may be useful in controlling impulsive behavioral outbursts. Sedatives (eg, a short-acting benzodiazepine such aslorazepam0.5 mg orally every 12 hours as needed) are sometimes used in the short term to alleviate event-related anxiety, but such treatment is not recommended for the long term. 