Dementia treatment

The first step in treating behavioral disorders is to determine their nature, possible causes, and complications. Treatment is planned based on the intensity, duration, and frequency of behavioral changes. Behavioral disorders may be exacerbated by the manner in which caregivers communicate. For example, the patient may not understand complex phrases. In this case, the caregiver should be encouraged to use shorter, simpler phrases, which may eliminate behavioral problems and make other methods unnecessary. Inappropriate behavior may attract attention and reduce the patient's isolation. If the caregiver realizes that the patient's inappropriate behavior is inadvertently reinforced by increased attention, other methods are needed to reduce the patient's isolation.

If possible, the patient's behavior should be analyzed from the point of view of the patient's basic needs. For example, if the patient constantly asks whether it is time for lunch (regardless of the actual time), then this is easily explained by the fact that he is hungry. It is more difficult to understand the patient's desire to relieve himself in a pot with plants, but it can be explained, for example, by the patient's fear of the toilet room, since when he enters there and sees his reflection in the mirror, he thinks that someone else is in the toilet room.

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

Approaches to the treatment of behavioral disorders may be aimed at changing the patient's level of stimulation. The patient can be talked about his past, which he usually remembers well due to the relative preservation of long-term memory. Neuropsychological examination or a thorough clinical interview will reveal the preserved neuropsychological functions, and attempts to occupy the patient should be based on those functions that are still strong. Behavioral disorders are often reduced when the patient's daily activities are carried out in accordance with a strict daily routine. The patient's activity should be controlled in such a way as to ensure an optimal level of stimulation. From this point of view, as experience shows, occupational therapy can be an effective method for correcting behavioral disorders in the elderly.

Psychotic disorders in patients with dementia may manifest themselves as delusions or hallucinations. The patient's delusional reasoning often involves "people who stole things." One possible reason for this pathological stinginess is that patients try to find an explanation for their problems caused by memory loss by confabulation. For example, if the search for an object has been fruitless, the patient concludes that the object was stolen. Identification disorder is another common disorder in patients with dementia. It may manifest itself in the pathological conviction that "this house is not mine" or "my spouse is actually a stranger." Looking at the TV or seeing their reflection in the mirror, patients may claim that "there are other people in the room." Identification disorder may be explained by visual-spatial disorders found in patients with Alzheimer's disease. Systematic delusions are rare in patients with dementia, as they suggest relative preservation of cognitive functions, in particular the ability to think abstractly. Visual hallucinations are more common in Alzheimer's disease than auditory ones.

Depressive syndrome. Previously existing depression may intensify in connection with the development of dementia. However, depressive symptoms often appear after the development of dementia. In any case, recognizing the symptoms of depression is important, since its treatment can improve the quality of life of patients and their caregivers. Depression can manifest itself as dysphoria, irritability, anxiety, negativism, uncontrollable crying. Although affective disorders may not reach the level that allows for concomitant major depression, bipolar disorder, or another formal diagnosis according to DSM-IV criteria, these symptoms can worsen the condition of patients and their caregivers. In this case, an antidepressant, mood stabilizer, or anxiolytic should be prescribed.

Sleep-wake disorders. Sleep-wake disorders can be another factor that negatively affects the quality of life of the patient and caregivers. If the patient does not sleep, then the patient and those around him/her develop fatigue, leading to an increase in other behavioral symptoms.

In patients with sleep-wake disorders, nonpharmacologic measures, including sleep hygiene measures and phototherapy, may be effective. A thorough examination may reveal an underlying cause that requires specific therapy, such as restless legs syndrome or sleep apnea. Sleep hygiene measures include avoiding daytime naps and using the bed only for sleep and sex. The bedroom should be kept at a comfortable temperature and free of external noise and light. If the patient cannot fall asleep within 30 minutes, the patient should be advised to get out of bed, leave the bedroom, and return to bed only when drowsy again. Warm milk or a warm bath before bedtime may help induce sleep. The patient's medications should be carefully reviewed and stimulants, such as caffeine, should be excluded or taken in the morning. If the patient is taking a hypnotic, it should be taken in the evening. Diuretics should be prescribed in the first half of the day. In addition, the patient should limit the amount of liquid consumed at night. It is advisable to go to bed and get up at the same time every day, regardless of the duration of sleep.

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

Pharmacological treatment of sleep-wake cycle disorders may involve the use of any traditional sleep aid, with the choice of drug based on the side effect profile. The ideal agent should act quickly and briefly, without causing next-day drowsiness, without adversely affecting cognitive function, and without causing dependence.

Anxiety. Anxiety in patients with dementia may be a manifestation of somatic diseases, side effects of medications or depression. After a thorough examination and analysis of the medications taken by the patient, the question of prescribing an anxiolytic or antidepressant can be decided. In some cases, it is possible to use a normothymic.

Wandering. A particular type of behavioral disorder, the danger of which depends largely on the location of the patient. Wandering by a patient left unsupervised in the city center near busy highways is extremely dangerous. But the same patient in a nursing home may wander around the garden under supervision with virtually no risk. Wandering must be considered in the context of its causes. It may be a side effect of certain medications. Other patients simply try to follow people passing by the house. Some try to look at a door or other objects that catch their eye from a distance. Understanding the causes of the patient's behavior is important in planning treatment. Nonpharmacological treatments for wandering include supervision to ensure the patient's safety, the use of identification bracelets ("safe return"), which are available through the Alzheimer's disease association. Another approach to treatment relies on the patient's retained behavioral patterns. Stop lights or facsimiles of signs placed on or near the exit door may prevent wandering. To achieve the same goal, one can take advantage of the visual-spatial disorders that develop in patients - special markings on the floor (for example, dark stripes) near the exit may be mistakenly perceived by patients as a depression or hole that should be avoided. In addition, exit doors should be locked with locks that patients will not be able to open. Distraction can have a temporary effect - the patient can be offered food or another activity that can bring him pleasure. Music can also have a similar distracting effect.

Medicines are used when non-drug measures have not been effective enough. Medicines from any class of psychotropic drugs can be of some benefit. The right medicine often has to be chosen by trial and error. Neuroleptics should be used with caution, as these drugs can increase wandering, causing akathisia. Sedatives increase the risk of falls in restless patients. According to preliminary data, cholinesterase inhibitors reduce aimless wandering in patients with Alzheimer's disease.

Apathy/anergia. Apathy and anergia are also observed in patients with dementia. In the late stage, patients seem almost completely detached due to memory and speech impairment, and complete inability to care for themselves. During the examination, it is necessary to first exclude reversible causes of anergia, such as delirium. Having excluded delirium or other conditions that can be treated quickly, the next step is to determine whether the cause of anergia or apathy is depression, which may respond to treatment with psychostimulants. In this case, antidepressants are also effective, but they act more slowly than psychostimulants.

Selection of drugs for the correction of behavioral disorders.

Neuroleptics. Schneider et al. (1990) performed a meta-analysis of a number of studies on the effectiveness of neuroleptics in the treatment of behavioral disorders in hospitalized patients with various types of dementia. On average, the effect of neuroleptics exceeded the effect of placebo by 18% (p < 0.05). However, these results should be taken with caution - due to the fact that the analyzed studies were conducted on heterogeneous samples of patients (including patients with various organic brain lesions), as well as the high effectiveness of placebo. Several studies have been conducted on the effectiveness of neuroleptics in the treatment of behavioral disorders in outpatients with dementia. However, the value of many of the studies is limited, since they did not have a control group of patients taking placebo, and the patient samples were also heterogeneous.

The existing data do not allow making a scientifically sound choice of a neuroleptic for the correction of behavioral disorders. In this regard, when choosing a drug, they are guided mainly by the side effect profile, which is different for different drugs. Low-potential neuroleptics more often cause sedative and anticholinergic effects, as well as orthostatic hypotension. Anticholinergic action can aggravate cognitive defects, provoke urinary retention, and increase constipation. When using high-potential neuroleptics, there is a higher risk of developing Parkinsonism. When using any neuroleptics, tardive dyskinesia may develop. As shown by individual controlled studies, new-generation neuroleptics, such as risperidone, clozapine, olanzapine, quetiapine, can be useful in the correction of behavioral disorders and are possibly better tolerated than traditional drugs, but they are not without side effects.

There are no scientifically based recommendations for choosing the optimal dose of neuroleptics for the correction of behavioral disorders in dementia. As a rule, lower doses are used in geriatric patients, and the dose is titrated more slowly. Experience shows that in patients with dementia and psychotic disorders, treatment with haloperidol should be started 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 is necessary in the first weeks after the start of treatment or a change in the dose of the drug. As a rule, treatment of psychosis in a patient with dementia takes from 6 to 12 weeks (Devenand, 1998).

Normotimic agents. The efficacy of carbamazepine in the treatment of behavioral disorders in patients with dementia is supported by data from open and double-blind, placebo-controlled studies conducted in nursing home settings. In a double-blind, placebo-controlled study, carbamazepine was effective at a mean dose of 300 mg/day, which was generally well tolerated. The duration of the therapeutic phase in this study was 5 weeks. The authors reported that the drug produced positive results with subsequent use.

Valproic acid is another mood stabilizer that may be useful in treating behavioral disturbances in dementia. However, its efficacy has only been demonstrated in uncontrolled trials in heterogeneous patient populations. The dose of valproic acid in these studies ranged from 240 to 1500 mg/day, with blood concentrations reaching 90 ng/L. Sedation may limit the dose of the drug. Liver function and clinical blood counts should be monitored during treatment with valproic acid.

Although lithium has been reported to have a beneficial effect on behavioral disturbances in some patients with dementia, it has been ineffective in the vast majority of cases. The potential for serious side effects requires caution when using the drug in geriatric patients in general and in patients with dementia in particular. Lithium salts are generally not recommended for patients with dementia unless they have bipolar disorder.

Anaxiolytics. The efficacy and safety of benzodiazepines in patients with dementia with behavioral disorders has not been sufficiently 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, which do not form active metabolites in the body.

Buspirone is a nonbenzodiazepine anxiolytic that is not addictive but may cause headache and dizziness. Controlled studies of buspirone in patients with dementia with behavioral disorders have not been conducted. One study compared the efficacy of haloperidol (1.5 mg/day) and buspirone (15 mg/day) in 26 patients with agitation in a nursing home. Buspirone reduced anxiety and tension. Both groups showed a tendency toward behavioral normalization, but there was no placebo control group in the study.

Zolpidem is a nonbenzodiazepine hypnotic. Low doses have been reported to reduce agitation in patients with dementia (Jackson et al., 1996). However, controlled trials of zolpidem in behavioral disorders have not been conducted.

Antidepressants. Trazodone, an alpha2-adrenergic receptor and 5-HT2 receptor antagonist, is commonly used as an antidepressant. Several reports have noted that at doses up to 400 mg daily, the drug can reduce agitation and aggression. A double-blind comparative study of trazodone and haloperidol demonstrated the efficacy of both drugs. Trazodone was more effective than haloperidol in reducing the severity of negativism, stereotypy, and verbal aggression. Patients taking trazodone dropped out of the study less often than patients taking haloperidol. The study did not have a placebo control group. In addition, delirium developed in some patients taking trazodone. Other side effects, such as orthostatic hypotension, drowsiness, and dizziness, also limit the use of trazodone.

SSRIs. Selective serotonin reuptake inhibitors (SSRIs) are widely used to correct behavioral disorders in dementia. Their ability to reduce agitation has been particularly well studied. Studies have shown the effectiveness of alapracolat, citalopram, and sertraline in the treatment of behavioral disorders. At the same time, the effectiveness of fluvoxamine and fluoxetine in the treatment of behavioral disorders in patients with dementia has not been proven in studies. Additional studies of drugs in this group are needed to clarify their role in the treatment of behavioral disorders.

Beta-blockers. Open studies have shown the ability of propranolol at a dose of up to 520 mg per day to reduce the severity of agitation in organic brain damage. However, bradycardia and arterial hypotension may prevent the drug from achieving an effective dose. According to some data, gastsolol may be as effective as propranolol, but does not have these side effects. Additional studies are needed to confirm this effect of beta-blockers. However, at present they can be recommended for the correction of agitation in patients with dementia.

Hormones: A small open-label study of men with dementia showed that conjugated estrogen and medroxyprogesterone acetate could reduce aggressive behavior.