Behavioral and psychological symptoms of dementia (BPSD), such as psychosis, aggression, sleep disturbance, agitation, and mood disorders, develop in most, if not all, elderly patients at some stage during the disease.1 These symptoms are likely to impair the quality of life of both patient and caregiver. In particular, aggression, paranoia and sleep disturbance can be particularly upsetting for family carers and increase the risk of institutionalization. Patients exhibiting BPSD should be assessed in a detailed clinical interview with an informant to establish which symptoms and behaviors cause distress or risk to the patient and/or caregiver. Intervention in BPSD should initially focus on non-pharmacological measures.2, 3 The quality of patient care should be optimized and potential physical, environmental, social and psychiatric triggers addressed where possible. Caregiver education, support and behavioral training can also be effective in alleviating BPSD.1 Appropriate pharmacotherapies for BPSD that persist despite non-pharmacological intervention include antipsychotics for agitation, aggression and psychotic symptoms, antidepressants for mood disorders, and anticonvulsants for non-psychotic agitation. Conventional antipsychotics have a modest benefit over placebo in the treatment of psychosis and agitation in dementia but are associated with treatment-emergent side effects such as extrapyamidal symptoms (EPS) and postural hypotension.4 Atypical antipsychotics are at least as effective as conventional antipsychotics, are better tolerated and have a lower propensity to cause EPS.4 Atypical antipsychotics have different receptor affinities and, therefore, side-effect profiles, and potential patient vulnerability to these side effects should drive individual treatment decisions. The need for prescribed treatment should be reviewed regularly and medication only continued if there is demonstrable evidence of efficacy while emergent side effects are carefully monitored. In conclusion, although mild BPSD often respond to simple environmental and psychosocial intervention, psychotropic drug therapy is often required particularly for more severe psychotic symptoms, aggression and agitated behavior. If optimally selected and monitored, antipsychotic drugs can improve these symptoms and have a positive impact on the quality of life of both the patient and their caregiver. References 1. Teri L, Logsdon RG, McCurry SM. Nonpharmacologic treatment of behavioral disturbance in dementia. Med Clin N Am 2002; 86: 641-656. 2. Small GN, Rabins PV, Barry PP, Buckholtz NS, DeKosky ST, Ferris SH, et al. Diagnosis and treatment of Alzheimer’s disease and related disorders: consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer’s Association, and the American Geriatrics Society. JAMA 1997; 278: 1363-1371. 3. Howard R, Ballard C, O’Brien J, Burns A. Guidelines for the management of agitation in dementia. Int J Geriatr Psychiatry 2001; 16: 714-717 4. Kindermann SS, Dolder CR, Bailey A, Katz IR, Jeste DV. Pharmacological treatment of psychosis and agitation in elderly patients with dementia: four decades of experience. Drugs Aging 2002; 19: 257-276.
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