Treatment of dementia

The first step in attracting behavioral disorders is to establish their nature, possible causes and complications. Therapeutic measures are planned taking into account the intensity, duration and frequency of behavioral changes. Strengthening behavioral disorders can be triggered by the manner of communication of persons caring for the patient. For example, a patient may not understand complex phrases. In this case, the caretaker should clarify the need to use shorter and simpler phrases that can eliminate behavioral problems and make other methods unnecessary. Inadequate behavior can attract the attention of others and reduce the isolation of the patient. If the caregiver realizes that the inadequate behavior of the patient is inadvertently reinforced by increased attention, other methods are required to reduce isolation of the patient.

If possible, the patient's behavior should be analyzed in terms of the patient's basic needs. For example, if the patient constantly asks if it is not time for lunch (regardless of real time), then this is easily explained by the fact that he is hungry. It is more difficult to understand the patient's desire to "small need" in a pot of plants, but it can be explained, for example, by the fear of the patient in front of the toilet room, because when he enters there and sees his reflection in the mirror, he thinks that there is someone in the toilet yet.

The cause of inadequate behavior may be a concomitant somatic disease. In patients with dementia, deterioration in the condition can be explained by pain, constipation, infection, and medication. Patients with dementia are often unable to describe their complaints and express their discomfort by changing behavior. The cause of inadequate behavior in a patient with dementia may be a concomitant mental illness.

Approaches to the treatment of behavioral disorders can be aimed at changing the level of stimulation of the patient. With the patient you can talk about his past, which he usually remembers well due to the relative safety of long-term memory. Neuropsychological research or a thorough clinical interview will reveal the preserved neuropsychological functions, and attempts to engage the patient must rely on those functions that he still has. Often behavioral disorders decrease when the patient's daily activity is carried out in accordance with the strict regime of the day. The activity of the patient should be controlled in such a way as to ensure the optimal level of its stimulation. From this point of view, experience shows that occupational therapy can be an effective method of correction of behavioral disorders in elderly people.

Psychotic disorders in patients with dementia can be manifested by delirium or hallucinations. In the delusional reasoning of the patient often act "people who stole things." One of the possible reasons for this pathological stinginess is that patients are trying to find an explanation for their problems, which have arisen because of a weakening of memory, through confabulation. For example, if the search for an item has been unsuccessful, the patient concludes that the item was stolen. Impaired identification is another frequent disorder in patients with dementia. It may manifest a pathological conviction that "this house is not mine" or "my husband is in fact a stranger". Looking at the TV or seeing their reflection in the mirror, patients can assert that "there are other people in the room". The violation of identification can be explained by visual-spatial disorders found in patients with Alzheimer's disease. Systematized delirium in patients with dementia is rare, because it involves the relative preservation of cognitive functions, in particular the ability to abstract thinking. Visual hallucinations in Alzheimer's disease are more common than auditory.

Depressive syndrome. In connection with the development of dementia, the previously existing depression may worsen. But often depressive symptoms appear after the development of dementia. In any case, the recognition of the symptoms of depression is important, since its treatment can improve the quality of life of patients and caregivers. Depression can be manifested by dysphoria, irritability, anxiety, negativism, uncontrollable crying. Although affective disorders may not reach levels consistent with the DSM-IV criteria for concomitant major depression, bipolar disorder, or other formal diagnosis, these symptoms can worsen the condition of patients and carers. In this case, you should prescribe an antidepressant, a normotime or an anxiolytic.

Sleep and wakefulness disorders. Sleep and wakefulness disorder can be another factor negatively affecting the quality of life of the patient and carers. If the patient does not sleep, then he and others develop fatigue, which leads to an increase in other behavioral symptoms.

In patients with sleep and wakefulness disorders, non-pharmacological methods may be effective, including measures for observing sleep hygiene and phototherapy. A thorough examination may reveal a cause that requires specific therapy, for example, restless legs syndrome or sleep apnea. Sleep hygiene measures include daytime sleep prevention and bed use only for sleeping and sex. The bedroom should be maintained at a comfortable temperature, there should be no external noises or light. If the patient can not fall asleep for 30 minutes, he is advised to get out of bed, leave the bedroom and go to bed only when he again feels drowsy. Help to fall asleep can warm milk or a warm bath before going to sleep. You should carefully analyze the medications that the patient takes, and exclude drugs with a stimulating effect, for example, caffeine-containing drugs, or postpone their administration in the morning. If the patient takes the drug with a hypnotic effect, his reception should be rescheduled for the evening. Diuretics should be administered in the morning. In addition, the patient should limit the amount of fluid that is drunk at night. It is advisable to go to bed and get up at the same time, regardless of the length of sleep.

Phototherapy can also have some benefit in the treatment of sleep disorders. In a pilot study, 10 hospitalized patients with Alzheimer's disease, suffering from twilight disorientation and sleep disorders, were exposed to bright light for 2 hours for 1 week for 1 week. Improvement in clinical scales was noted in 8 of these patients.

Pharmacological treatment of sleep and wakeful sleep disorders may involve the use of any traditional sleeping pills, while the choice of the drug is based on the side-effects profile. The ideal tool should act quickly and briefly, without causing drowsiness the next day, without adversely affecting cognitive functions and without causing addiction.

Anxiety. Anxiety in patients with dementia may be a manifestation of somatic diseases, side effects of drugs or depression. After a thorough examination and analysis of medications taken by the patient, the question of the appointment of an anxiolytic or an antidepressant may be resolved. In some cases, the use of normotimics is possible.

Wandering. A special type of behavioral disorder, the danger of which largely depends on the patient's location. Wandering of a patient left unattended in the center of the city near busy thoroughfares presents an exceptional danger. But the same patient in a nursing home can wander around the garden under supervision with little or no risk. Wanderings should be considered in the context of its causes. It can be a side effect of certain medicines. Other patients simply try to follow people walking by the house. Some try to consider the door or other objects that attracted their attention at a distance. When planning treatment, it is important to understand the causes of the patient's behavior. Non-pharmacological methods of treatment of wandering include surveillance to ensure the safety of the patient, the use of identification bracelets ("safe return"), which can be obtained through the association of Alzheimer's disease. Another direction in the treatment relies on the behavioral stereotypes preserved in patients. Stop lamps or facsimile signs placed on or near the exit door can prevent wandering. To achieve the same goal, it is possible to take advantage of developing visual-spatial disorders in patients - special markings on the floor (for example, dark streaks) near the exit can be mistaken for patients as a recess or hole, which should be avoided. In addition, it is necessary to lock the exit doors with locks, which patients can not open. A temporary effect can give distraction - the patient can be offered food or another occupation that can bring him pleasure. A similar distraction can be enjoyed by music.

Medicines are used when non-pharmacological measures are not effective enough. A certain benefit can be brought by drugs from any class of psychotropic drugs. You often have to choose the right tool by trial and error. With care, neuroleptics should be used, since these drugs can intensify wandering, causing akathisia. Preparations with sedative action increase the risk of falls in restless patients. According to preliminary data, cholinesterase inhibitors reduce the aimless vacillations in patients with Alzheimer's disease.

Apathy / anergy. Apathy and anergy are also observed in patients with dementia. At a late stage, patients seem almost completely detached due to memory impairment, speech, total inability to care for themselves. In the course of the survey, it is necessary first and foremost to eliminate the reversible causes of energy, for example, delirium. Excluding delirium or other conditions in which you can get a quick effect from the treatment, the next step is to determine if depression is the cause of anergy or apathy, which can respond to treatment with stimulants. In this case, antidepressants are also effective, but they are slower than psychostimulants.

Choice of medicines for correction of behavioral disorders.

Neuroleptics. Schneider et al. (1990) performed a meta-analysis of a series of studies of the efficacy of antipsychotics in the treatment of behavioral disorders in hospitalized patients with different variants of dementia. On average, the effect of antipsychotics exceeded the placebo effect by 18% (p <0.05). However, these results should be taken with caution - because the analyzed studies were conducted on heterogeneous samples of patients (among whom were patients with various organic brain lesions), as well as high placebo efficacy. Several studies of the efficacy of neuroleptics in the treatment of behavioral disorders and in outpatients with dementia have been carried out. However, the value of many of the studies performed is limited, since they lacked a control group of patients taking placebo, and the patient samples were also heterogeneous.

Existing data do not allow us to make a scientifically based choice of neuroleptic for the correction of behavioral disorders. In this regard, when choosing a drug, they are guided mainly by a profile of side effects, which are not the same for different drugs. Low-potential neuroleptics often cause sedative and cholinolytic effects, as well as orthostatic hypotension. Holinolytic action can aggravate the cognitive defect, provoke a delay in urine, strengthen constipation. When using high-potential neuroleptics, the risk of developing parkinsonism is higher. With the use of any antipsychotics, the development of tardive dyskinesia is possible. As shown by separate controlled trials, new generation antipsychotics such as risperidone, clozapine, olanzapine, quetiapine may be useful in correcting behavioral disorders and may be better tolerated than traditional drugs, but they are not without side effects.

There are no scientifically substantiated recommendations on the choice of the optimal dose of neuroleptic for correction of behavioral disorders in dementia. As a rule, lower doses are used in geriatric patients, and dose titration is slower. Experience shows that in patients with dementia and psychotic disorders, treatment with haloperidol should begin with a dose of 0.25-0.5 mg per day. However, in some patients, even this dose causes severe Parkinsonism. In this regard, careful monitoring of the patient's condition in the first weeks after the start of treatment or changing the dose of the drug. Typically, the treatment of psychosis in a patient with dementia takes 6 to 12 weeks (Devenand, 1998).

Normotimicheskie means. The effectiveness of carbamazepine in the treatment of behavioral disorders in patients with dementia is confirmed by data from open and double-blind placebo-controlled studies conducted in nursing facilities. In a double-blind, placebo-controlled study, carbamazepine was effective at an average dose of 300 mg / day, which, as a rule, was well tolerated. The duration of the therapeutic phase in this study was 5 weeks. The authors reported that with further use the drug gave positive results.

Valproic acid is another normotimic agent that can be useful in attracting behavioral disorders in dementia. Nevertheless, the effectiveness of the drug was shown only in uncontrolled trials on heterogeneous samples of patients. The dose of valproic acid in these studies ranged from 240 to 1500 mg / day, and the concentration of the drug in the blood reached 90 ng / l. Sedation may limit the dose of the drug. When treating valproic acid, it is necessary to monitor liver function and clinical blood analysis.

Although the positive effect of lithium drugs on behavioral disorders in some patients with dementia was reported, in most cases they were ineffective. The possibility of serious side effects requires caution when using the drug in geriatric patients in general and patients with dementia in particular. As a rule, lithium salts are not recommended for patients with dementia, if they do not suffer from bipolar disorder.

Anaxiolytics. The effectiveness and safety of benzodiazepines in patients with dementia with behavioral disorders has not been adequately studied. These drugs can cause dependence, drowsiness, amnesia, disinhibition and falls. At the same time, they can be useful in the treatment of anxiety and sleep disorders. Preference should be given to lorazepam and oxazepam, not forming active metabolites in the body.

Buspirone - a non-benzodiazepine anxiolytic - does not cause dependence, but can provoke headache and dizziness. Controlled studies of buspirone in patients with dementia with behavioral disorders have not been conducted. In one study, the efficacy of haloperidol (1.5 mg / day) and buspirone (15 mg / day) was compared in 26 patients with excitation in a nursing facility. Against the background of buspirone, there was a decrease in anxiety and tension. In both groups there was a tendency to normalize behavior, however, the control group taking placebo was not in the study.

Zolpidem is a nonbenzodiazepine hypnotic. The ability of small doses of the drug to reduce excitation in patients with dementia has been reported (Jackson et al., 1996). However, controlled trials of zolpidem in behavioral disorders have not been conducted.

Aide depressants. Trazodone, which is an antagonist of alpha2-adrenoreceptors and 5-HT2 receptors, is usually used as an antidepressant. Several reports noted that in a dose up to 400 mg per day, the drug can reduce agitation and aggression. In a double-blind, comparative study of trazodone and haloperidol, the efficacy of both drugs is shown. Trazodone is more effective than haloperidol, reducing the severity of negativity, stereotypy and verbal aggression. Patients who took trazodone, less likely to leave the study than patients who took haloperidol. The study did not have a control group of patients taking placebo. In addition, in individual patients who took trazodone, delirium developed. The use of trazodone also limits other side effects, such as orthostatic hypotension, drowsiness and dizziness.

SSRIs. Selective serotonin reuptake inhibitors (SSRIs) are widely used to correct behavioral disorders in dementia. Especially well studied is their ability to reduce agitation. In studies, the effectiveness of alaprakolata, citalopram and sertraline in the treatment of behavioral disorders is shown. At the same time, the effectiveness of fluvoxamine and fluoxetine in the treatment of behavioral disorders in patients with dementia in studies has not been proven. It is necessary to further study the drugs of this group in order to clarify their role in the treatment of behavioral disorders.

Beta-blockers. In open studies, the ability of propranolol in a dose of up to 520 mg per day to reduce the severity of excitation with organic brain lesions. However, bradycardia and arterial hypotension can interfere with the achievement of an effective dose of the drug. According to some reports, gaccholol can be as effective as propranolol, but it does not have these side effects. More research is needed to confirm this effect of beta-blockers. However, even now they can be recommended for correction of excitation in patients with dementia.

Hormones. In a small open study of men with dementia, the ability of conjugated estrogen and medroxyprogesterone acetate is shown to reduce aggressive actions.