Management of Neuropsychiatric Symptoms of Dementia in Clinical Settings: Recommendations from a Multidisciplinary Expert Panel

Abstract

Non-cognitive neuropsychiatric symptoms (NPS) of dementia include aggression, agitation, depression, anxiety, delusions, hallucinations, apathy, and disinhibition. These affect dementia patients nearly universally across dementia stages and etiologies. NPS are associated with poor patient and caregiver outcomes including excess morbidity and mortality, increased health care utilization, and earlier nursing home placement, as well as caregiver stress, depression and reduced employment. While there is no FDA-approved pharmacotherapy for NPS, psychotropic medications are frequently used to manage these symptoms. However, in the few cases of proven pharmacologic efficacy, benefit may be off set by significant risk of adverse effects. Non-pharmacologic treatments, typically considered first-line, also show evidence for efficacy as well as a limited potential for adverse effects. However, their uptake as preferred treatments remains inadequate in real-world clinical settings. Thus, the field currently finds itself between a “rock and a hard place” in terms of management of these difficult symptoms. It was in this context that the University of Michigan Program for Positive Aging, working in collaboration with the Johns Hopkins Alzheimer’s Disease Research Center and Center for Innovative Care in Aging sponsored and convened a multidisciplinary expert panel in Detroit Michigan in Fall 2011 with three objectives, to: 1) define key elements of care for NPS in dementia; 2) construct an approach describing the sequential and iterative steps of managing NPS in real-world clinical settings that can be used as a basis for integrating non-pharmacologic and pharmacologic approaches; 3) discuss how the approach generated could be implemented in research and clinical care.

Management of Patients With Alzheimer’s Disease

“…всей оставшейся жизни. В идеальном варианте члены семьи, ухаживающие лица и лечащие врачи (семейные врачи, неврологи, психиатры), психологи образуют еди-ную команду, обеспечивающую различные нелекарствен-ные методы лечения [6,7]. Члены семьи и ухаживающие лица сообщают врачам об изменении состояния пациен-та, эффективности различных методов терапии.…”

A preclinical screen to evaluate pharmacotherapies for the treatment of agitation in dementia

“…The treatment of agitation has been identified as an unmet need in relation to adequate care provided for those suffering from cognitive impairments (Gitlin et al, 2012;Herrmann and Lanctot, 2007). When the agitation is severe the symptoms include disinhibition, irritability, aggression and aberrant motor activity, which affect the patient's quality of life and cause increased stress for the family and caregivers (Antonsdottir et al, 2015;Cummings et al, 2015;Panza et al, 2015;Kales et al, 2014).…”

Improving Dementia Care Through Behavioral Interventions

“…These symptoms are highly prevalent, affecting almost all patients with dementia at some point during the course of their illness [1]. Dementiarelated NPS can be categorized as behavioral excesses (eg, agitation, aggressiveness, repetitive vocalizations, or pacing) or behavioral deficits (eg, withdrawal, apathy, or failure to initiate or engage in self-care or social activities); alternatively, they can be classified as behaviors that are dangerous (threatening caregivers or striking out) or as behaviors that annoy others but are not dangerous (hoarding or repetitive behaviors) [7].Historically, antipsychotic and sedative medications were used to help manage dementia-related NPS; however, these uses are not approved by the US Food and Drug Administration (FDA). Importantly, studies over the past decade have demonstrated that antipsychotic medications have limited efficacy when used for this purpose, and there is also an increased risk of death in elderly patients who receive antipsychotic medications.…”

“…These symptoms are highly prevalent, affecting almost all patients with dementia at some point during the course of their illness [1]. Dementiarelated NPS can be categorized as behavioral excesses (eg, agitation, aggressiveness, repetitive vocalizations, or pacing) or behavioral deficits (eg, withdrawal, apathy, or failure to initiate or engage in self-care or social activities); alternatively, they can be classified as behaviors that are dangerous (threatening caregivers or striking out) or as behaviors that annoy others but are not dangerous (hoarding or repetitive behaviors) [7].…”

“…There are several core features of effective behavioral intervention programs for NPS: they teach caregivers about the nature of the brain damage that occurs in dementia, so that caregivers develop more realistic expectations of the abilities of the person with dementia; they use a systematic approach to understanding NPS triggers and measuring responses to interventions in order to reduce the frequency and severity of behavioral symptoms; they teach caregivers to alter their interactions with the person with dementia to avoid NPS triggers; they advocate controlling the environment of care to avoid both overstimulation and understimulation of the patient; they capitalize on the preserved abilities of patients to form rudimentary motor or stimulus-response memories of pleasant daily events; and they use an individualized, person-centered, systematic approach to problem solving that includes evaluation of the patient's response over time and adjustment of the plan based on the patient's response. An interdisciplinary panel of experts recently summarized core elements of the behavioral approach to dementia-related NPS using the acronym DICE: describe, investigate, create, and evaluate [7].…”