The majority of patients with Alzheimer’s disease (AD) develop significant behavioural symptoms during the dementia phase of their illness, significantly impacting illness course, relationships, caregiver abilities and quality of life. For example, psychosis manifested by delusions or hallucinations, and persistent aggression each occur in approximately one-third of patients. Non-specific, chronic agitation can be a significant problem as well. The presence of many of these behaviours is associated with faster cognitive decline. Moreover, caring for patients with dementia, particularly when behavioural symptoms are present, is often frustrating. Recently, it has been appreciated that significant behavioral disturbances can occur in the mild cognitive impairment phase just before the onset of dementia and the diagnosis of AD.
It is possible to conceptualise several behavioural syndromes within the context of Alzheimer’s dementia: psychosis, depression, sleep disturbance, and chronic agitation. There are current draft criteria for psychosis of AD and depression of AD that are used to aid clinical appreciation and research.
Neuroimaging studies suggest that delusions and other behaviours in AD are related to right frontal hypometabolism and to relatively greater neuropsychological deficits in executive function. Neurochemical correlates suggest dysfunction in multiple neurotransmitter systems, including norepinephrine-, serotonin-, dopamine-, acetylcholine- and glutamate-mediated systems.
Effective treatments for behavioural disturbances have the potential to improve symptoms and clinical progression of illness, delay institutionalisation, and lessen illness and treatment burden. Current non-pharmacological and pharmacological treatment approaches will be overviewed. Non-pharmacological treatment includes adaptation of living environment, caregiver coping strategies, and direct interventions with patients. Each of which may result in considerable benefit throughout the illness course.
Although there is a range of pharmacological approaches, none has been approved for the treatment of specific behavioural syndromes or symptoms in AD. Nevertheless, the current regulatory milieu allows for the potential recognition of medications effective in treating psychosis of AD and depression of AD, as well as acute agitation. Antipsychotic, antidepressant, anxiolytic, and anticholinesterases are frequently used based on experience and a growing evidence base.
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