Decoding and Treating Neuropsychiatric Symptoms in Dementia

Abstract

In assessing the neuropsychiatric symptoms of patients with dementia, Laura C. Hanson, MD, MPH, a professor in the division of geriatric medicine at the University of North Carolina at Chapel Hill, said one of her main teaching points is to avoid use of the nonspecific term “agitation.” “The term I use is physical restlessness or emotional restlessness, which I find to be at least slightly more descriptive than agitation ... We can better work [from there] on identifying underlying factors,” Dr. Hanson said during a dementia panel discussion at the annual meeting of the American Geriatrics Society. Some 85% of individuals with moderate to severe dementia experience neuropsychiatric symptoms, which can be caused by environmental triggers, distressing caregiver behaviors, lack of stimulation, physical pain, or other factors. “We know from a variety of descriptive studies that a very high percentage of people with even moderate and later-stage dementia are able to self-report pain,” she emphasized. Words are easier than numbers, however. “It is not worth asking them to rate their pain on a 1 to 10 scale. But they can answer the question, ‘Are you in pain now?’ or ‘Are you in discomfort now?’ They may respond better [to the word] discomfort,” she said. “Ask slowly — they may need time to answer. And we need to use our clinical observation skills.” At least one well-designed randomized controlled trial — a Norwegian trial of 352 nursing home residents — has shown that treating pain improves neuropsychiatric distress in patients with moderate to severe dementia, Dr. Hanson said. The residents randomized to an individualized stepwise pain treatment protocol beginning with an acetaminophen equivalent and “moving all the way [if necessary] to low-dose opioids” were more likely to have significant reductions in pain, agitation, and psychiatric symptoms than residents who received usual care (BMJ 2011;343:d4065). These findings “suggest there is a strong linkage between some neuropsychiatric distress and pain,” Dr. Hanson said. Depression should also be considered when neuropsychiatric symptoms are reported — they affect 25% of individuals with early-stage Alzheimer’s and significantly more who have vascular dementia — as should akathisia and psychosis in some cases. “I often ask myself, is it akathisia, a neurologic syndrome of physical restlessness that could be a side effect of an antipsychotic?” Dr. Hanson said. “And I also ask, are there psychotic symptoms involved, which could in some cases point to a medical delirium?” Unfortunately, “with depression, the treatment evidence is inconclusive for our ability to intervene with traditional SSRIs or other antidepressants,” she said. “Probably the most important evidence-based point is to avoid benzodiazepines when a person is expressing anxiety and sadness and has underlying dementia.” Otherwise, the treatment of neuropsychiatric symptoms is about symptom management with nonpharmacologic interventions. “Begin with decoding internal or environmental triggers for distress and reversing them,” she advised. Then use music, aroma, and other sensory modalities; most of these nonpharmacologic interventions are supported by moderate-quality evidence. Christine Kilgore is a freelance writer in Falls Church, VA.