Managing the behavioral and psychological signs and symptoms of dementia

Sensory stimulation for persons with dementia: a review of the literature

AIMS AND OBJECTIVES

To provide an overview of available sensory stimulation interventions, and their effect on persons with dementia and to present theoretical and methodological characteristics of the studies included.

BACKGROUND

Different sensory stimulation interventions are used for persons with dementia to increase alertness, reduce agitation and improve quality of life. However, the effect of these interventions is not clear, neither are their characteristics.

DESIGN

A systematic search and review of the literature with description of the content and an evaluation of theoretical and methodological approaches.

METHODS

Systematic searches in CINAHL, PubMed (Medline), The Cochrane library and PsycINFO. Studies included have been subject to quality assessment by means of Critical Appraisal Skills Programme.

RESULTS

Fifty-five studies were included and thirty of these documented significant effect. The effect of the sensory stimulation interventions mainly reported on negative behaviours, except from five studies assessing quality of life and well-being. The majority of the studies had methodological limitations. The different sensory stimulation interventions were organised into eight categories: music, light therapy, acupressure/reflexology, massage/aromatherapy and doll therapy/pet therapy/toy therapy, the Sonas programme and Snoezelen.

CONCLUSIONS

More studies are needed to clarify appropriate substantial background for the specific interventions. However, most of the studies based their interventions on a theoretical foundation. Furthermore, more research is needed to measure the effect of sensory stimulation on communication as well as quality of life. In addition, studies are to focus on whether the effect depends on the stage of dementia.

RELEVANCE TO CLINICAL PRACTICE

Nurses are to be aware of sensory stimulation as a possible intervention to improve persons' quality of life.

Anxiety and stigma in dementia: a threat to aging in place

The number of Americans with dementia is expected to increase as the population ages. Developing dementia is feared by many older adults and may result in anxiety in persons with dementia. This article focuses on anxiety, one of the least understood symptoms associated with dementia in community-dwelling older adults, the stigma of dementia, and the relationship between anxiety and stigma in dementia. When undetected and untreated, anxiety and associated stigma can adversely affect quality of life and the ability to age in place.

Alzheimer's disease

BACKGROUND

The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental treatment of patients with Alzheimer's disease (AD).

STUDIES REVIEWED

The authors conducted MEDLINE searches for 2000 through 2005 using the terms "Alzheimer's disease," "geriatric," "epidemiology," "pathophysiology," "treatment" and "dentistry." Reports selected for further review included those published in English in peer-reviewed journals. The authors gave preference to articles reporting randomized, controlled trials.

RESULTS

AD is a progressive and fatal neurodegenerative disorder characterized by cognitive dysfunctions, particularly in learning and memory, and the emergence of behavioral abnormalities. Deficiencies in the cells responsible for storage and processing of information underlie the cognitive, functional and behavioral changes seen in patients with the disorder.

CLINICAL IMPLICATIONS

As the elderly population grows, increasing numbers of Americans with AD will require dental treatment. The prevalence of dental disease likely will be extensive, because of diminished salivary flow and patients' inability to perform appropriate oral hygiene techniques. Preventive dental education for the caregiver and use of saliva substitutes and anticaries agents by the patient are indicated.

Behavioural symptoms of dementia in residential settings: a selective review of non-pharmacological interventions

For people with dementia living in residential settings, behaviours such as aggression, screaming, restlessness, agitation and wandering are a frequent reason for referral to specialist mental health services for older people. Psychosocial models of dementia have grown in prominence and non-pharmacological interventions have been recommended in professional and government policy statements, either as a first line of treatment or alongside medication. Studies of their effectiveness have been criticised for being poorly controlled, focusing on milder behaviour problems and for requiring a disproportionate use of resources. The recent ruling that risperidone and olanzepine should not be used to control behavioural symptoms in dementia makes it timely to review the evidence for alternative treatments. The current review is a selective one of different types of studies including studies of staff training and liaison interventions, studies of a range of different therapeutic interventions and individualized interventions within a single-case methodology. It is argued that different types of research methodology are appropriate for different studies and that there is still too little evidence to provide firm guidelines. In conclusion, a structured decision-making process for selection of interventions is proposed, in which the limited available evidence can be drawn together to provide a basis for targeting clinical resources while the research evidence is strengthened.

Pharmacological treatment of psychosis and agitation in elderly patients with dementia: four decades of experience

A number of studies, using different research designs and assessment instruments, have been conducted to elucidate the differential effects of drug treatments for psychosis, agitation and aggression in elderly patients with dementia. We have reviewed literature published from 1960 to 2000 on this topic; 48 studies that met our selection criteria were identified from Medline and Science Citation Index. Antipsychotic medication was generally effective for the treatment of psychosis and agitation in elderly patients with dementia. In double-blind, placebo-controlled trials in this population, mean improvement rates were 61% with antipsychotics and 35% with placebo. Atypical antipsychotics appeared promising, but the number of well-designed studies has been small so far. Methodological limitations of the studies reviewed are discussed; future trials should ensure adequate sample size and duration and involve direct comparisons of individual medications. In conclusion, conventional antipsychotics are modestly effective for treatment of psychosis and agitation in elderly individuals with dementia, whereas newer treatments such as atypical antipsychotics appear to be at least as effective while having fewer adverse effects. Nonetheless, there is no currently available ideal pharmacotherapy, and psychosocial management is a necessary part of overall treatment. Additional large-scale, well-controlled studies are needed before conclusive statements regarding the value of treatment of psychosis and agitation with atypical antipsychotics and non-antipsychotic agents can be made.

Efficacy and safety of risperidone oral solution in agitation associated with dementia in the elderly

BACKGROUND

Behavioral and psychological symptoms in dementia (BPSD) contribute to caregiver burden and institutionalization of elderly. Neuroleptics are prescribed to control agitation. Side effects of typical neuroleptics are harmful, making atypical neuroleptics an indication.

OBJECTIVES

To evaluate efficacy and tolerability of risperidone oral solution (ROS) given once daily to demented elderly outpatients with BPSD (agitation).

METHOD

Patients (n=26), 76.35+/-8.63 years, Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) criteria for dementia. RSO was given, starting dose of 0.25 mg and increments of 0.25 mg every week. Mini-Mental State Examination (MMSE) assessed cognitive status, Behavioral and Emotional Activities Manifested in Dementia (BEAM-D) and Clinical Global Impression (CGI) measured BPSD, Extrapiramidal Symptom Rating Scale (ESRS) evaluated extrapyramidal symptoms. Cardiovascular side effects were evaluated clinically.

RESULTS

There was a 26% reduction in agitation and no cardiovascular side effects in the range from 1.0 to 1.25 mg. Side effects were more prevalent above 2.5 mg.

CONCLUSION

Risperidone oral solution improved agitation with good tolerability from 0.5 to 1.25 mg. A single dose with increments of 0.25 mg may be more acceptable to patients and caregivers.

Psychotropic drug use in elderly people with and without dementia

OBJECTIVE

To determine the prevalence of psychotropic drug use in very old persons with and without dementia in two time periods, and describe the patterns of psychotropic drug use between institutions and non-institutions.

METHODS

Descriptive analysis on a sample of subjects aged 81+ from a population-based study in Stockholm, Sweden. Psychotropic drug use data were collected from the 1987-1989 and 1994-1996 periods of the study. The diagnosis of dementia was based on the DSM III-R.

RESULTS

About 41% of the subjects used at least one psychotropic drug in both periods. Women and subjects in institutions more commonly used psychotropic drugs. The most commonly reported were, in rank order, hypnotics-sedatives, anxiolytics, antipsychotics and antidepressants. Hypnotics-sedatives and anxiolytics were the most commonly used in both institutions and non-institutions. More persons with dementia used psychotropic drugs in both periods. The use of newer drugs, for example, SSRI, was evident. Multivariate analyses showed increased risk for psychotropic drug use among subjects in institutions.

CONCLUSIONS

This study confirms the high rate of psychotropic drug use in the very old, particularly in persons with dementia. Psychotropic drug use was high among subjects living in institutions.

A short-term inpatient program for agitated demented nursing home residents

OBJECTIVE

This case series describes the various contributors of disruptive behavior in demented nursing home residents and outlines the necessary steps to identify and treat them.

DESIGN

Evaluation of overall clinical improvement and agitation at discharge from the hospital and at follow-up.

SETTING

Nursing home residents consecutively admitted to the geriatric psychiatry service of a psychiatric university hospital in the New York metropolitan area.

PATIENTS

15 elderly demented nursing home residents with agitation.

MEASURES

Overall clinical improvement was assessed with the 'global assessment of functioning scale'. Agitation was evaluated with the 'brief agitation rating scale' and the 'nursing home scale for agitation'. Medication side-effects were measured with the 'Simpson-Angus scale' and the 'abnormal involuntary movement scale'.

RESULTS

The patients showed significantly more overall clinical improvement at discharge compared with admission. Additionally, agitation scores were significantly lower at discharge and at follow-up compared with admission.

CONCLUSION

A comprehensive medical and neurological assessment, an accurate identification of comorbid psychopathology, evaluation of drug toxicity, and a thorough history of psychotropic medication trials are essential steps for a successful treatment.

Use of drugs by Old Age Psychiatrists in the treatment of psychotic and behavioural symptoms in patients with dementia

The objective was to elicit the prescribing practises of Old Age Psychiatrists in the UK in the treatment of psychotic and behavioural symptoms in patients with dementia. A structured questionnaire was sent to all Old Age Psychiatrists in the United Kingdom. Respondents were questioned regarding their use of both typical and atypical antipsychotics and the most common dosages prescribed. Information was sought about usage of depot medication and dosages; use of alternative or adjunctive medications to antipsychotics and use of parenteral medication for acute management of agitation. The most commonly used antipsychotic to treat psychotic symptoms was haloperidol, and thioridazine to treat behavioural symptoms. A wide range of dosages was used. Use of depot medication was common, with flupenthixol decanoate being the most frequently used. Most respondents use at least one of the atypical antipsychotics, risperidone being most popular. Use of other psychotropic medication used as alternatives to antipsychotics or adjunctives in the treatment of behavioural symptoms was common, the most popular being trazodone. Of the respondents, 62.7% use parenteral medication for the acute management of agitation, the most popular drug being haloperidol. The typical antipsychotics are still the most commonly used despite the reputed better safety profile of the atypicals. There was wide variation in the dosages prescribed. Use of psychotropics other than phenothiazines was common. More research is needed into the use of psychotropic medication for dementia and there is need for consensus in this area. Forming an expert group may be the best way to create uniformity of prescription.

A risk-benefit assessment of risperidone for the treatment of behavioural and psychological symptoms in dementia

The importance of behavioural and psychological symptoms in dementia (BPSD) is increasingly being recognised. Symptoms such as verbal and physical aggression, agitation, sleep disturbances and wandering are common, cause great distress to caregivers and are likely to lead to institutionalisation of patients. At present, these symptoms are also more amenable to treatment compared with the progressive intellectual decline caused by dementing illnesses. The care of individuals with BPSD involves a broad range of psychosocial treatments for the patient and his or her family. If pharmacotherapy is deemed necessary to manage BPSD, a careful balance must be struck between the benefits of symptom control and the inherent risks associated with most psychotropic agents in the elderly. Elderly patients in general, and patients with dementia in particular, are more sensitive to medication adverse effects, including anticholinergic effects, orthostatic hypotension, sedation, parkinsonism, tardive dyskinesia and cognitive impairment than younger patients with dementia or individuals without dementia. To date, treatment of symptoms of aggression and psychosis has relied on the empirical use of antidepressants, anxiolytics, typical antipsychotics (neuroleptics) and other agents. Treatment-limiting adverse effects are frequently reported with all of these agents. However, it is the typical antipsychotics and the atypical antipsychotic clozapine that are associated with the greatest risk of adverse effects in the elderly. The present review highlights the issues that limit the use of older psychotropic agents in the elderly, and presents an assessment of the available evidence concerning the efficacy, safety and tolerability of the atypical antipsychotic risperidone, in the treatment of BPSD in elderly patients with dementia. The extensive clinical development programme for risperidone has shown the drug to be effective and well tolerated in many fragile patients. As a result of its efficacy and safety profile, risperidone can be used for the treatment of behavioural and psychological symptoms in patients with dementia. Risperidone therefore represents a significant addition to the armamentarium for BPSD. While efforts continue in the development of treatment for the cognitive decline associated with dementia, treatment is now available for the noncognitive symptoms. By treating the latter, risperidone has the potential to be of substantial benefit to patients with dementia, their carers and the costs of healthcare.