MANAGEMENT OF
DEMENTIA
Jonathan T. Stewart, MD
Professor in Psychiatry
University of South Florida College of Medicine
Chief, Geropsychiatry Section
Bay Pines VA Medical Center
DEMENTIA
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Affects 10% of Americans over 65
Fourth most common cause of death
Only 10% of cases are reversible or
arrestable
DEMENTIA: BEHAVIORAL
PROBLEMS
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Present in 80% of cases
Major source of caregiver stress,
institutionalization
Common at all stages of the disease
Much more treatable than the
underlying dementia
Poorly described in the literature
THE DEMENTIA WORKUP
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Thorough history
Physical examination
Mental status examination
Blood work
Neuroimaging study
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70% degenerative dementia
20% vascular dementia
10% other
TWO TYPES OF DEMENTIA
POSTROLANDIC
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Memory deficits
Aphasia
Apraxia
Agnosia
Personality
preserved
MMSE valid
FRONTAL/SUBCORTICAL
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Memory deficits
Loss of goal-oriented behavior,
behavioral plasticity
Personality changes
– Disinhibition
– Abulia
Incontinence
MMSE useless
FRONTAL/SUBCORTICAL CIRCUITS
Frontal cortex
Subcortical white matter
Striatum
Pallidum
Thalamus
THREE SYNDROMES
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Loss of goal-oriented behavior
(dorsolateral prefrontal circuit)
Abulia (anterior cingulate circuit)
Disinhibition (orbitofrontal circuit)
Don’t miss this one:
DIFFUSE LEWY BODY
DISEASE
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Postrolandic dementia
– More rapidly progressive than AD
– Fluctuation, episodes of “pseudodelirium” common
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Mild parkinsonism
– Tremor often absent
– Poor response to antiparkinsonian meds
– Shy-Drager sx’s common
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Prominent psychotic sx’s, esp visual
hallucinations
SEVERE NEUROLEPTIC INTOLERANCE
NEUROLEPTICS AND DLBD
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Most patients have severe reactions to
neuroleptics, including severe akinesia,
dystonias and NMS-like syndromes
Increases LOS in 81%; reduces lifespan in
50% (McKeith et al, 1992)
Doubles rate of cognitive decline (McShane et al,
1997)
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A severe, unexpected reaction to low-dose
neuroleptics is highly suggestive of DLBD
MEDICATIONS FOR
ALZHEIMER’S DISEASE
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Donepezil
Rivastigmine
Galantamine
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Memantine
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net change in MMSE
A TYPICAL STUDY
3
2.5
2
1.5
1
0.5
0
-0.5
-1
-1.5
-2
-2.5
-3
Drug X
Placebo
0
12
24
36
study week
52
60
BEWARE!
Effect of 14 weeks drug X
treatment in mild or moderately
severe Alzheimer’s disease
As it appears in the paper
The whole story
32
70
31.5
60
31
50
30
Drug X
29.5
Placebo
29
28.5
ADAS-cog score
ADAS-cog score
30.5
40
Drug X
Placebo
30
20
28
10
27.5
0
27
0
14
weeks
0
14
weeks
MANAGEMENT
OTHER
MEDS
WOOF.
THE BEST NUMBER OF
MEDICATIONS TO USE IS
ZERO (or sometimes one)
WHEN IN DOUBT, GET RID OF
MEDICATIONS!
THREE BASIC PRINCIPLES
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STRUCTURE
LIMITED GOALS
THE “NO-FAIL” ENVIRONMENT
“THE CUSTOMER
IS ALWAYS
RIGHT!”
SOME “NO-FAIL”
TECHNIQUES
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Remove challenges from the
environment
Don’t correct unless absolutely
necessary
Distract, change the subject
Always help the patient save face
The “universal mistake” technique
Validation therapy
DEPRESSION
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15-30% incidence in Alzheimer’s
disease
Often early in the course of the illness
Sometimes previous personal or family
history of depression
Most important treatable cause of
excess disability
Responds very well to treatment
TYPICAL SYMPTOMS OF
DEPRESSION
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Mood symptoms
“Cognitive” symptoms
Vegetative symptoms
OTHER POSSIBLE
SYMPTOMS OF DEPRESSION
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Anxiety
Fearfulness
Somatization
Excessive complaining, requests for
help (Kunik et al, 1999)
“Personality change”
Screaming (Greenwald et al, 1986; CohenMansfield et al, 1990)
DEPRESSION: TREATMENT
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Selective serotonin reuptake inhibitors
Tricyclics
Other agents
ECT
AGITATION
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Present in 40-80% of patients
Up to 34% of patients are combative
Few predictors
It is unusual for medications to be
dramatically effective
ACUTE BEHAVIOR CHANGE
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I atrogenic
I nfection
I llness
I njury
I mpaction
I nconsistency
I s the patient depressed?
“SUNDOWNING”
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4 PM
2 AM
MANAGING SLEEP
DISTURBANCE
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Increase time cues (“Zeitgebers”)
Aerobic exercise
Restrict caffeine and alcohol
Restrict naps
Manage incontinence, pain
Keep the room cool and quiet
Don’t forget the night-light
Hypnotics (NOT ANTIHISTAMINES!)
CATASTROPHIC REACTIONS
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“A substantive emotional reaction
precipitated by task failure.” (Goldstein,
1952)
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Responds well to a “no-fail”
environment, but not really to meds
RESISTIVENESS
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Common in patients with severe
dementia or frontal/subcortical disease
LIMIT GOALS
Slow, gentle approach
“As soon as we do this, I’ll leave you
alone.”
Premedication with lorazepam may help
PSYCHOTIC SYMPTOMS IN
DEMENTIA
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50% incidence, esp. in moderate
dementia
Includes:
– Delusions (usu. theft, jealousy or “living in
the past”)
– Hallucinations (usu. “phantom boarder”)
– Reduplicative paramnesia
– Misidentification of mirror, TV, etc.
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MEDS ARE OFTEN NOT NEEDED
MANAGING PSYCHOSIS
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Rule out acute decompensation
Is it really a psychosis?
Is treatment really necessary?
Try non-pharmacologic techniques first
Try to stick to low-dose atypicals (mainly for
delusions); don’t use anticholinergics
Goals of therapy are quite modest
Try to dechallenge neuroleptics every three
months
COMMON SIDE-EFFECTS OF
TYPICAL NEUROLEPTICS
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Parkinsonian symptoms
Akathisia
Neuroleptic malignant syndrome
Tardive dyskinesia
Functional decline
Cognitive decline
ATYPICAL NEUROLEPTICS
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Clozapine
Risperidone
Olanzapine
Quetiapine
Ziprasidone
Aripiprazole
DISINHIBITION
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Mostly in frontal/subcortical disease
Use antecedent control and
environmental manipulation, not operant
conditioning
Can use anticonvulsants, propranolol,
other agents for aggression
Can use SSRI’s or antiandrogenics for
sexual disinhibition
SCREAMING
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Seen in severely demented patients
Multifactorial:
– RESTRAINT
– Pain, discomfort
– Sensory deprivation
– Depression (?)
EMPIRICALLY EFFECTIVE
MEDS FOR AGITATION
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Anticonvulsants
Atypical neuroleptics (best when
agitation is clearly related to psychosis)
Trazodone
Buspirone
Lorazepam, oxazepam
MORE HEROIC OPTIONS
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Lithium
Beta-blockers
Narcotics
Estrogens
Typical neuroleptics
ECT
THE BEST NUMBER OF
MEDICATIONS TO USE IS
ZERO (or sometimes one)
WHEN IN DOUBT, GET RID OF
MEDICATIONS!
WANDERING
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Up to 2/3 of patients
Can lead to serious injury or death
Four types:
– Exit seekers
– Self stimulators
– Akathisiacs
– Modelers
(Hussian, 1987)
WANDERING:
MANAGEMENT
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Manage sleep disturbance aggressively
Discontinue neuroleptics if possible
Exercise, stimulation, outdoor time
Alarms
Visual barriers
Locks (consider fire hazard, though)
Medicalert bracelet, police registry, etc.
DON’T FORGET SAFETY
ISSUES!
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Driving
Firearms
Power tools
Smoking in bed
Poisons, medications
Fall risk
GOOD LUCK!
MEDS
OTHER
WOOF!