Each recommendation is identified as falling into one of three categories of endorsement, based on the level of confidence regarding the recommendation, as indicated by a bracketed Roman numeral after the statement. Definitions of the categories of endorsement are presented at the end of the "Major Recommendations" field.
Patients with dementia display a broad range of cognitive impairments and neuropsychiatric symptoms that can cause significant distress to themselves and caregivers. As a result, individualized and multimodal treatment plans are required [I]. Dementia is usually progressive, and treatment must evolve with time in order to address newly emerging issues [I]. At each stage the psychiatrist should be vigilant for symptoms likely to be present, should identify and treat co-occurring psychiatric and medical conditions, and should help patients and families anticipate future symptoms and the care likely to be required [I].
- Psychiatric Management
The treatment of patients with dementia should be based on a thorough psychiatric, neurological, and general medical evaluation of the nature and cause of the cognitive deficits and associated noncognitive symptoms, in the context of a solid alliance with the patient and family [I]. It is particularly critical to identify and treat general medical conditions, most notably delirium, that may be responsible for or contribute to the dementia or associated neuropsychiatric symptoms [I].
Ongoing assessment includes periodic monitoring of the development and evolution of cognitive and noncognitive psychiatric symptoms and their response to intervention [I]. In order to offer prompt treatment, enhance safety, and provide timely advice to the patient and family, it is generally necessary to see patients in routine follow-up at least every 3 to 6 months [II]. More frequent visits (e.g., up to once or twice a week) or even psychiatric hospitalization may be required for patients with acute, complex, or potentially dangerous symptoms or for the administration of specific therapies [I]. Recommended assessments include evaluation of suicidality, dangerousness to self and others, and the potential for aggression, as well as evaluation of living conditions, safety of the environment, adequacy of supervision, and evidence of neglect or abuse [I].
All patients and families should be informed that even mild dementia increases the risk of vehicular accidents [I]. Mildly impaired patients should be advised to limit their driving to safer situations or to stop driving [I], and moderately impaired patients should be instructed not to drive [I]. Advice about driving cessation should also be communicated to family members, as the implementation of the recommendation often falls on them [I]. Relevant state laws regarding notification should be followed [I].
Important aspects of psychiatric management include educating patients and families about the illness, its treatment, and sources of additional care and support (e.g., support groups, respite care, nursing homes, and other long-term-care facilities) and advising patients and their families of the need for financial and legal planning due to the patient's eventual incapacity (e.g., power of attorney for medical and financial decisions, an up-to-date will, and the cost of long-term care) [I].
- Specific Psychotherapies and Other Psychosocial Treatments
In addition to the general psychosocial interventions subsumed under psychiatric management, a number of specific interventions are appropriate for some patients. Few of these treatments have been subjected to double-blind randomized evaluation, but some research, along with clinical practice, supports their effectiveness. Behavior-oriented treatments are used to identify the antecedents and consequences of problem behaviors and attempt to reduce the frequency of behaviors by directing changes in the environment that alter these antecedents and consequences. Behavioral approaches have not been subjected to large randomized clinical trials but are supported by small trials and case studies and are in widespread clinical use [II]. Stimulation-oriented treatments, such as recreational activity, art therapy, music therapy, and pet therapy, along with other formal and informal means of maximizing pleasurable activities for patients, have modest support from clinical trials for improving behavior, mood, and, to a lesser extent, function, and common sense supports their use as part of the humane care of patients [II]. Among the emotion-oriented treatments, supportive psychotherapy can be employed to address issues of loss in the early stages of dementia [II]. Reminiscence therapy has some modest research support for improvement of mood and behavior [III]; validation therapy and sensory integration have less research support [III]; none of these modalities has been subjected to rigorous testing. Cognition-oriented treatments, such as reality orientation, cognitive retraining, and skills training focused on specific cognitive deficits, are unlikely to have a persistent benefit and have been associated with frustration in some patients [III].
- Special Concerns Regarding Somatic Treatments for Elderly Patients and Patients With Dementia
Medications are effective in the management of some symptoms associated with dementia, but they must be used with caution in this patient population [I]. Because age may alter the absorption, distribution, metabolism, and elimination of many medications, elderly individuals may be more sensitive to their effects. General medical conditions and use of more than one medication may further affect the pharmacokinetics of many medications. In addition, patients with dementia may be more likely to experience certain medication adverse effects, including anticholinergic effects, orthostasis, sedation, and parkinsonism. Finally, symptoms of dementia may alter medication adherence in ways that are unsafe. Consequently, when using pharmacotherapy in patients with dementia, low starting doses, small increases in dose, and long intervals between dose increments may be needed, in addition to ensuring that a system is in place that can enhance proper medication adherence [I].
- Treatment of Cognitive Symptoms
Three cholinesterase inhibitors—donepezil, rivastigmine, and galantamine—are approved by the U.S. Food and Drug Administration (FDA) for treatment of mild to moderate Alzheimer's disease, and donepezil has been approved by the FDA for severe Alzheimer's disease. These medications have similar rates of adverse effects and have been shown to lead to modest benefits in a substantial minority of patients (i.e., 30%–40% in clinical trials). These medications should be offered to patients with mild to moderate Alzheimer's disease after a thorough discussion of their potential risks and benefits [I], and they may be helpful for patients with severe Alzheimer's disease [II].
Cholinesterase inhibitors should be considered for patients with mild to moderate dementia associated with Parkinson's disease [I]. Only rivastigmine has been approved by the FDA for this indication, but there is no reason to believe the benefit is specific to this cholinesterase inhibitor.
Cholinesterase inhibitors can be considered for patients with dementia with Lewy bodies [II].
The constructs of mild cognitive impairment and vascular dementia are evolving and have ambiguous boundaries with Alzheimer's disease. The efficacy and safety of cholinesterase inhibitors for patients with these disorders are uncertain; therefore, no specific recommendation can be made at this time, although individual patients may benefit from these agents [II].
Memantine, a noncompetitive N-methyl-D-aspartate (NMDA) antagonist, which has been approved by the FDA for use in patients with moderate and severe Alzheimer's disease, may provide modest benefits and has few adverse effects; thus, it may be considered for such patients [I]. There is some evidence of its benefit in mild Alzheimer's disease [III] and very limited evidence of its benefit in vascular dementia [I].
Vitamin E (alpha-tocopherol) is no longer recommended for the treatment of cognitive symptoms of dementia because of limited evidence for its efficacy as well as safety concerns [II].
Nonsteroidal anti-inflammatory agents (NSAIDs), statin medications, and estrogen supplementation (with conjugated equine estrogens) have shown a lack of efficacy and safety in placebo-controlled trials in patients with Alzheimer's disease and therefore are not recommended [I].
- Treatment of Psychosis and Agitation
Psychosis, aggression, and agitation are common in patients with dementia and may respond to similar therapies. When deciding if treatment is indicated, it is critical to consider the safety of the patient and those around him or her [I]. A careful evaluation for general medical, psychiatric, environmental, or psychosocial problems that may underlie the disturbance should be undertaken [I]. If possible and safe, such underlying causes should be treated first [I]. If this does not resolve the symptoms, and if they do not cause significant danger or distress to the patient or others, such symptoms are best treated with environmental measures, including reassurance and redirection [I]. For agitation, some of the behavioral measures discussed in Item 2 above may also be helpful [II]. If these measures are unsuccessful or the behaviors are particularly dangerous or distressing, then the symptoms may be treated judiciously with one of the agents discussed in the following paragraphs [II]. The use of such agents should be reevaluated and their benefit documented on an ongoing basis [I].
On the basis of good evidence, antipsychotic medications are recommended for the treatment of psychosis in patients with dementia [II] and for the treatment of agitation [II]. These medications have also been shown to provide modest improvement in behavioral symptoms in general [I]. Evidence for the efficacy of these agents is based mostly on 6–12-week trials in nursing home residents and outpatients. There is limited research on their use beyond 12 weeks, but considerable clinical experience supports this practice [II]. Evidence for a difference in efficacy and safety among antipsychotic medications is limited. Antipsychotic medications as a group are associated with a number of severe adverse events, including increased risks for death, cerebrovascular accidents, tardive dyskinesia, neuroleptic malignant syndrome, hyperlipidemia, weight gain, diabetes mellitus, sedation, parkinsonism, and worsening of cognition. Thus, they must be used with caution and at the lowest effective dosage [I], after considering the risks of not treating the psychiatric symptoms [I]. Patients and families should be advised about potential benefits and risks of antipsychotic agents, particularly the risk of mortality [I]. Second-generation (atypical) antipsychotics currently have a black box warning for increased risk of mortality in elderly patients; recent data suggest that first-generation (typical) agents carry at least a similar risk. High-potency agents tend to cause akathisia and parkinsonian symptoms; low-potency agents tend to cause sedation, confusion, delirium, postural hypotension, and peripheral anticholinergic effects. The decision of which antipsychotic to use is based on the relationship between the side-effect profile and the characteristics of the individual patient [I].
Data demonstrating benefit from benzodiazepines are modest, but benzodiazepines occasionally have a role in treating patients with prominent anxiety [III] or on an as-needed basis for patients with infrequent episodes of agitation or for those who require sedation for a procedure such as a tooth extraction or a diagnostic examination [II]. Adverse effects of benzodiazepines include sedation, worsening cognition, delirium, increased risk of falls, and worsening of breathing disorders. Lorazepam and oxazepam, which have no active metabolites, are preferable to agents with a longer half-life such as diazepam or clonazepam [III].
There is minimal evidence for the efficacy of anticonvulsants, lithium, and beta-blockers for the treatment of psychosis or agitation in dementia, and these medications have significant adverse effects; therefore, they are generally not recommended except for patients for whom other treatments have failed [III]. The antidepressant trazodone and the selective serotonin reuptake inhibitors (SSRIs) are also not well studied for symptoms other than depression but may be appropriate for nonpsychotic patients with agitation, especially for patients with mild agitation or prior sensitivity to antipsychotic medications [III].
- Treatment of Depression
Depression is common in patients with dementia. Patients with depression should be evaluated for suicide risk [I]. Depressed mood may respond to improvements in the patient's living situation or to stimulation-oriented treatments [II]. Although evidence for antidepressant efficacy in patients with dementia and depression is mixed, clinical consensus supports a trial of an antidepressant to treat clinically significant, persistent depressed mood [II]. The choice among agents is based on the side-effect profile of specific medications and the characteristics of the individual patient [I]. SSRIs may be preferred because they appear to be better tolerated than other antidepressants [II]. Bupropion, venlafaxine, and mirtazapine may also be effective [II]. Agents with substantial anticholinergic effects (e.g., amitriptyline, imipramine) should be avoided [I]. Despite the lack of research data, clinical experience suggests that unilateral electroconvulsive therapy (ECT) may be effective for patients who do not respond to pharmacological agents [II].
Treatments for apathy are not well supported, but psychostimulants, bupropion, bromocriptine, and amantadine may be helpful [III]. Psychostimulants are also sometimes useful in the treatment of depression in patients with significant general medical illness [III].
- Treatment of Sleep Disturbances
Sleep disturbances are common in patients with dementia. Interventions include maintaining daytime activities and giving careful attention to sleep hygiene [II]. Pharmacological intervention could be considered when other approaches have failed [II]. If a patient also requires medication for another psychiatric condition, an agent with sedating properties, given at bedtime, could be selected [I]. For primarily treating the sleep disturbance, medications with possible effectiveness include trazodone, zolpidem, or zaleplon [III], but there are few data on the efficacy of specific agents. Benzodiazepines are not recommended for other than brief use because of risks of daytime sedation, tolerance, rebound insomnia, worsening cognition, falls, disinhibition, and delirium [II]. Diphenhydramine is not recommended because of its anticholinergic properties [II]. Antipsychotic medications should not be used solely for the purpose of treating sleep disturbances [I].
- Special Issues for Long-Term Care
Many patients eventually require long-term-care placement; approximately two-thirds of nursing home patients have dementia. Care should be organized to meet the needs of patients, including those with behavioral problems [I]. Employing staff with knowledge and experience concerning dementia and the management of difficult behavior is important [II]. Special care units may offer more optimal care, although there is limited evidence that they achieve better outcomes than traditional units [III].
A particular concern is the use of physical restraints and medications to control disruptive behavior. Appropriate use of antipsychotic medications can relieve symptoms and reduce distress and can increase safety for patients, other residents, and staff [I]. However, their use may be associated with worsening cognitive impairment, oversedation, falls, tardive dyskinesia, and neuroleptic malignant syndrome, as well as with hyperlipidemia, weight gain, diabetes mellitus, cerebrovascular accidents, and death [I]. Thus, good clinical practice requires careful consideration and documentation of the indications and available alternatives, both initially and on a regular ongoing basis [I]. A dose decrease or discontinuation should be considered periodically for all patients who receive antipsychotic medications [I]. A structured education program for staff may help to both manage patients' behavior and decrease the use of these medications in nursing homes [II]. Physical restraints are rarely indicated and should be used only for patients who pose an imminent risk of physical harm to themselves or others [I]. Reasons for the use of physical restraints should be carefully documented [I]. The need for restraints can be decreased by environmental changes that decrease the risk of falls or wandering and by careful assessment and treatment of possible causes of agitation [II].
