Alzheimer’s disease is a chronic, progressive neurodegenerative brain disorder that affects a patient’s memory, language, judgment, decision-making, planning, and organizing.
Alzheimer’s disease (AD) remains the most common cause of dementia. There are currently 5.3 million Americans affected by the disease, and as the aging population increases without a disease-modifying treatment, it is projected to be 15 million by 2050.
AD is a complex disease; hence, the treatment can at times be complicated and often challenging to the treating physicians. Successful treatment of patients with AD requires a thorough understanding of the patient and the family dynamic. AD, like any other chronic condition, may have other medical and psychiatric co-morbidities that need to be addressed. Treating the AD with anti-dementia drugs is a small part of the comprehensive management of AD. The discussion of medical co-morbidities are beyond the scope of this article; however, the psychiatric co-morbidities such as depression, anxiety, delusions, hallucinations, agitation, and aggression will be discussed. Some patients may have an undiagnosed personality disorder that resurfaces as the patient’s ability to compensate diminishes.
The physicians who treat patients with AD need to keep in mind that the management of this disease is more than just memory medication. Even among the patients with AD, the presentation and the course of the disease varies. Therefore, the successful management of AD requires a comprehensive approach not only to the memory but also the co-morbidities. Care managers provide an invaluable resource to both the development of a comprehensive approach but also an ongoing plan to support the individual with AD and its co-morbidities.
Depression affects 20% to 32% of patients with dementia, though more prevalent in vascular dementia as compared to AD. The diagnosis and treatment of depression in patients with dementia is quite challenging as it can be an early manifestation of dementia or cause of the dementia called pseudodementia. The depression can fluctuate and the presentation may vary, such as difficulty with attention and focusing, apathy, anxiety, and agitation as opposed to feelings of guilt, insomnia, hypersomnia, or suicidality. There may also exist an undiagnosed bipolar depression that needs attention, as the treatment is somewhat different. There are several scales to assess depression in patients with dementia, such as Geriatric depression scale, Hamilton depression, and Cornell scale for depression. The treatment of depression in dementia includes pharmacotherapy and psychosocial modalities, although ECT has been used for severe cases. The SSRIs remain the mainstay of treatments and have a better safety profile, as these patients are prone to medication side effects. In the case of bipolar depression, treatment with mood stabilizers may improve the patient’s mood. This may be one of the reasons that Depakote has been effective in treating some patients with dementia. Psychosocial stimulation, such as supportive therapy, focusing on positive aspects of life, happy memories, enjoyable experiences, and previous accomplishments, is an effective non-pharmacological approach to depression.
Anxiety affects 20% of patients with dementia. In the initial stages of the disease is the fear of losing control. Generalized anxiety disorder occurs in 5% of patients with AD. As the disease progresses, the anxiety level can fluctuate depending on the living situation and the patient’s support structure. Patients may present with restlessness, irritability, fatigue, and sleep disturbance. Anxiety like depression can be measured using standard scales such as Worry scale, which is a self-report in mild dementia, and Rating Anxiety in Dementia relies on all available data to rate the anxiety. This includes the caregiver report and patient observation. Treatment of anxiety includes social intervention such as milieu therapy, addressing the patient’s specific stressors or environmental factors, and pharmacotherapy, although this approach needs to be addressed with extreme caution as patients with dementia are sensitive to tranquilizers. The initial approach should b a trial of SSRI antidepressants, as most drugs in this class also treat anxiety successfully. In generalized anxiety disorders, Buspirone can also be helpful.
Delusions and hallucinations have been present in 15% to 20% of patients with dementia and increase with the disease progression. Hospital-induced psychosis, such as delirium during a hospital stay secondary to a urinary tract infection or pneumonia, could be the first manifestation of dementia in an elderly population. The delusions are usually persecutory and misidentification as part of the triad, the agnosia seen in patients with AD. Paranoid delusion of intruders and missing personal possessions are common. Some patients do not recognize family members or their own home, and some report seeing dead relatives, animals, and children in the house as part of visual hallucinations. The psychotic symptoms are often accompanied by agitation and aggressive behavior. The psychosis is often elicited from the patient or caregiver and by the use of scales such as BEHAVE-AD, dementia psychosis scale, or NPI (Neuropsychiatric Interview). The treatment of psychosis in dementia is quite challenging as the new data reports increased risk of cardiovascular-related death in elderly patients with dementia. As long as the psychosis is not disruptive to the patient and family, it does not have to be treated. Behavioral and environmental interventions, such as avoiding confrontation and argument, gentle touching, and environmental modifications are the first line therapy and should be employed in combination with psychopharmalogical therapy. This requires a tremendous patience on the part of the caregiver, as it tends to occur quite frequently.
In the cases where some form of antipsychotic treatment must be used for patient and family safety, the newer antipsychotic drugs such as Abilify, Seroquel, Zyprexa, Geodon or Risperdal are recommended. These drugs have a better side effect profile on extra pyramidal symptoms such as Parkinsonism, sedation, anticholinergic side effects, and orthostatic hypotension and tardive dyskinesia. Older antipsychotic drugs such as Haldol and Thorazine should be avoided at all costs. The patients and their families should be informed of the black box warnings related antipsychotic drugs. It is also important to recognize depression-induced psychosis, which may improve by treating the patients with antidepressants such as SSRIs. Bipolar depression can also present with psychosis during manic episodes. As mentioned earlier, psychosis could be a manifestation of an underlying medical condition that needs a thorough investigation.
Agitation and Aggression
Among patients with dementia, 27% exhibit agitation and/or aggressive behavior. There are two categories of agitation/aggression in dementia: one with psychosis, such as delusions and hallucination, and the other without psychosis. Agitation/aggression should be thoroughly investigated as it can signal an underlying medical condition or a patient need that cannot be properly communicated, such as hunger, thirst, pain, or a need for toileting. It can also be secondary to the underlying dementia, depression, or anxiety. These symptoms are particularly important, as it can be a concern for patient and/or caregiver safety. Patients with severe agitation are often angry with others, especially with the caregiver. They often resist help, such as shower, getting dressed, or toileting. Patients with dementia often get agitated in a new environment such as hospital or a new facility, or with new caregivers, or due to drug side effects. For example, certain tranquilizers and anticholinergic drugs that are used for bladder control can cause agitation in these patients. So the cause should be sought and addressed first. The environmental modification and supportive therapy is the mainstay of the treatment. Physical restraints should be the last resort only in cases where the patient is a danger to himself or others. The medications such as antidepressants, mood stabilizes, and if needed, antipsychotics can be used, again with special attention to the potential side effects.
One important psychiatric co-morbidity that is often overlooked by physicians caring for patients with dementia is undiagnosed personality disorder that can explain many of the behavioral disturbances that accompany a difficult patient. The patients with personality disorder pose a real challenge to the treating physician, as the patients are not aware of their illness. Unfortunately the diagnosis of this comorbidity is quite difficult and the treatment almost impossible. Caregivers, as part of a care management team, may help in the ongoing assessment of these behaviors and be utilized to intervene with both behavioral restructuring and maintenance of a pharmacotherapy program as prescribed.
The psychiatric co-morbidities in patients with AD could be either part of the dementia or an undiagnosed condition. In either case, it is the second most important issue that needs to be addressed and treated. It is important to keep in mind that the treatment of dementia is not just memory treatment that has been the main focus of dementia treatment. The successful management of patients with dementia in general and Alzheimer’s dementia in particular is treating all symptoms of disease. Once the assessment is completed and AD is confirmed, an ongoing care plan may be developed, supervised, and modified, as appropriate, using the services of care managers working in conjunction with clients, family members, and other members of the larger care team.
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Reprinted with permission from Aginglife.org. Contact Advocare Care Management and get the help you need.