Evaluating the Behavioral and Psychological Symptoms of Dementia

Patient EB is an 84-year-old woman who is living with her two nieces. She moved to the United States at age 22, never married, and worked in the fashion industry in New York, retiring at age 65. She has memory problems (denies having conversations, constantly repeats questions), problems with executive functioning (she has great difficulty managing her finances and has inappropriately given away money), and visuospatial functioning (she can become lost walking in her neighborhood). She also entirely denies any cognitive deficits and does not understand why she needs to live with her nieces. She is agitated and this agitation is expressed by constantly berating her nieces, denying her problems, and attempting to wander in the neighborhood. Her nieces are extremely frustrated in attempting to care for her. We diagnosed her with Alzheimer’s disease and then had a discussion with the patient and her nieces regarding treatments.

Quick Start

The behavioral and psychological symptoms of dementia	• The behavioral and psychological symptoms of dementia are usually the most difficult symptoms for patients and caregivers to manage. • Symptoms usually assessed on the basis of interviews with patients and relatives include apathy, anxiety, depression, hallucinations, and delusions. • Symptoms usually identified on the basis of observation of patient behavior include aggression, screaming, restlessness, agitation, wandering, culturally inappropriate behaviors, sexual disinhibition, hoarding, cursing, and shadowing.
Benefits of treatment	• Improves quality of life for patients and caregivers. • Reduces caregiver stress. • Reduces the likelihood of institutionalization. • Decreases the patient’s dependence upon the caregiver. • May improve cognition and function.
Evaluating behavioral and psychological symptoms of dementia	• It is important for the clinician to evaluate: • Apathy • Mood • Depression • Anxiety • Psychosis • Agitation • Disinhibition • Hallucinations • Delusions.
Formulating a treatment plan	• Caring for and educating the caregiver ( Chapter 22 ) • Non-pharmacological treatment of the patient ( Chapter 23 ) • Pharmacological treatment of the patient ( Chapter 24 ).

Recall the case of EB from Chapter 15 . Until now we have been discussing treatments for the cognitive aspects of Alzheimer’s disease. But, as case EB demonstrates, changes in cognition and the problems that ensue because of it are only part of the problem in Alzheimer’s disease (as well as other dementing illnesses). There are accompanying behavioral symptoms as well, which have significant management consequences. To wit, we have learned from our families that, in many respects, the stresses and demands of caring for a patient with behavioral problems is often the primary challenge. As one caregiver succinctly characterized the challenges in dealing with the behavioral and psychological symptoms of dementia:

When my wife would forget to buy my favorite foods at the supermarket I was upset, but when she started screaming at me to get out of our bed because she did not sleep with strangers, I knew the disease had reached a whole different level.

There has been considerable effort in recent years to develop both behavioral and pharmacological treatments for what has become known as “the behavioral and psychological signs and symptoms of dementia” ( ; ). Clinicians now realize that caring for these symptoms is a central part of caring for the patient with Alzheimer’s disease and other dementias ( Table 21-1 ).

TABLE 21-1

Dementias and Selected Neurodegenerative Disorders That Commonly Manifest Behavioral and Psychological Symptoms

Behavioral/Psychological Symptom	Dementia
Apathy	• Alzheimer’s disease • Vascular dementia • Frontotemporal dementia • Dementia with Lewy bodies • Corticobasal degeneration
Depression	• Alzheimer’s disease • Parkinson’s disease • Vascular dementia • Corticobasal degeneration • Dementia with Lewy bodies
Hallucinations	• Dementia with Lewy bodies • Parkinson’s disease (following treatment with dopaminergic agonists) • Vascular dementia (if infarcts involve the visual system)
Delusions	• Alzheimer’s disease • Dementia with Lewy bodies • Parkinson’s disease (following treatment with dopaminergic agonists)
Agitation/aggression	• Alzheimer’s disease • Dementia with Lewy bodies • Frontotemporal dementia
Disinhibition	• Frontotemporal dementia