P TO 50% OF COMMUNITYdwelling elderly individuals older than 85 years have dementia, with Alzheimer disease (AD), vascular dementia, and dementia with Lewy bodies accounting for most cases. 1,2 Although cognitive deficits are the clinical hallmark of dementing illnesses, noncognitive symptoms are common and can dominate disease presentation. These include an array of neuropsychiatric symptoms, such as agitation, aggression, delusions, hallucinations, repetitive vocalizations, and wandering, among other symptoms. Neuropsychiatric symptoms have been observed in 60% to 98% of patients with dementia, [3][4][5][6][7] especially in later stages, and are associated with caregiver stress and depression, as well as reduced caregiver employment and income. [8][9][10][11][12][13] Neuropsychiatric symptoms are also associated with increased hospital lengths of stay 14 and commonly lead to nursing home placement. [15][16][17] Federal expenditures for dementia are expected to triple in the next 10 years 18 and 30% of the cost of caring for patients with AD is attributed directly to the management of neuropsychiatric CME available online at www.jama.com Context Neuropsychiatric symptoms of dementia are common and associated with poor outcomes for patients and caregivers. Although nonpharmacological interventions should be the first line of treatment, a wide variety of pharmacological agents are used in the management of neuropsychiatric symptoms; therefore, concise, current, evidence-based recommendations are needed.Objective To evaluate the efficacy of pharmacological agents used in the treatment of neuropsychiatric symptoms of dementia.Evidence Acquisition A systematic review of English-language articles published from 1966 to July 2004 using MEDLINE, the Cochrane Database of Systematic Reviews, and a manual search of bibliographies was conducted. Inclusion criteria were double-blind, placebo-controlled, randomized controlled trials (RCTs) or metaanalyses of any drug therapy for patients with dementia that included neuropsychiatric outcomes. Trials reporting only depression outcomes were excluded. Data on the inclusion criteria, patients, methods, results, and quality of each study were independently abstracted. Twenty-nine articles met inclusion criteria.Evidence Synthesis For typical antipsychotics, 2 meta-analyses and 2 RCTs were included. Generally, no difference among specific agents was found, efficacy was small at best, and adverse effects were common. Six RCTs with atypical antipsychotics were included; results showed modest, statistically significant efficacy of olanzapine and risperidone, with minimal adverse effects at lower doses. Atypical antipsychotics are associated with an increased risk of stroke. There have been no RCTs designed to directly compare the efficacy of typical and atypical antipsychotics. Five trials of antidepressants were included; results showed no efficacy for treating neuropsychiatric symptoms other than depression, with the exception of 1 study of citalopram. For mood stabilizers, 3 RCTs in...

Leptin is a peptide hormone secreted by adipocytes. It has been shown to modulate production and clearance of amyloid beta (Aβ) in rodent models. We sought to determine if serum leptin was associated with cognitive decline in the elderly.We studied 2871 well-functioning elders, aged 70-79, who were enrolled in a prospective study. Serum leptin concentrations were measured at baseline and analyzed by mean ± 1 SD. Clinically significantly cognitive decline over 4 years was defined as ≥ 5 point drop on the Modified Mini Mental State Exam (3MS).Compared to those in the lower leptin groups, elders in the high leptin group had less cognitive decline, 20.5% vs. 24.7% (OR=0.79 95% CI 0.61-1.02, p=0.07). After adjustment for demographic and clinical variables, including body mass index and total percent body fat, those in the high leptin group had significantly less likelihood of cognitive decline, OR=0.66 (95% CI 0.48-0.91). We conclude that in elderly individuals, higher serum leptin appears to protect against cognitive decline, independent of comorbidites and body fat. HHS Public Access

No abstract

No abstract

In this sample of depressed nursing home residents treated with mirtazapine orally disintegrating tablets, advanced age, medical illness, and cognitive impairment did not predict response. The findings suggest that these variables need not be viewed as obstacles to treatment.