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Behavioral and Psychiatric Alzheimer's Symptoms

By: the Alzheimer's Association

What are behavioral and psychiatric symptoms of Alzheimer’s disease?

When Alzheimer’s disrupts memory, language, thinking and reasoning, these effects are referred to as “cognitive symptoms” of the disease. The term “behavioral and psychiatric symptoms” describes a large group of additional symptoms that occur to at least some degree in many, but by no means all, individuals with Alzheimer’s. In early stages of the disease, people may experience personality changes such as irritability, anxiety or depression. In later stages, other symptoms may occur, including sleep disturbances; agitation (physical or verbal outbursts, general emotional distress, restlessness, pacing, shredding paper or tissues, yelling); delusions (firmly held belief in things that are not real); or hallucinations (seeing, hearing or feeling things that are not there).

Many individuals with Alzheimer’s and their families find behavioral and psychiatric symptoms to be the most challenging and distressing effects of the disease. These symptoms are often a determining factor in a family’s decision to place a loved one in residential care. They also often have an enormous impact on care and quality of life for individuals living in long-term care facilities.

Evaluation of behavioral and psychiatric symptoms

The chief underlying cause of behavioral and psychiatric symptoms is the progressive deterioration of brain cells in Alzheimer’s disease. However, a number of potentially correctable medical conditions, drug side effects and environmental influences may also be important contributing factors. Successful treatment depends on recognizing which symptoms the person is experiencing, making a careful assessment, and identifying possible causes. With proper treatment and intervention, significant reduction or stabilization of symptoms can often be achieved. Behavioral and psychiatric symptoms may reflect an under-lying medical condition that causes pain or contributes to difficulty making sense out of the world. Anyone experiencing behavioral symptoms should receive a thorough medical evaluation, especially when symptoms appear suddenly. Examples of treatable conditions that may trigger behavioral symptoms include infections of the ear, sinuses, urinary or respiratory tracts; constipation; and uncorrected problems with hearing or vision.

Side effects of prescription medication are another common contributing factor to behavioral symptoms. Side effects are especially likely to occur when individuals are taking multiple medications for several health conditions, creating a potential for drug interactions.

Situations that may play a role in behavioral symptoms include moving to a new residence or nursing home; other changes in the environment or caregiver arrangements; misperceived threats; or fear and fatigue resulting from trying to make sense out of an increasingly confusing world

Non-drug treatment strategies

The two major types of treatment for behavioral and psychiatric symptoms are non-drug strategies and prescription medications. Non-drug approaches should be tried first. In general, steps to developing non-drug management strategies include (1) identifying the symptom, (2) under-standing its cause, and (3) adapting the caregiving environment to remedy the situation. Correctly identifying what has triggered behavior can often help in selecting the best intervention. Often the trigger is some sort of change in the person’s environment, such as change in caregiver or in living arrangements; travel; admission to a hospital; presence of houseguests; or being asked to bathe or change clothing.

A key principle of intervention is redirecting the person’s attention, rather than arguing or being confrontational. Additional strategies include the following:

• Simplify the environment, tasks and routines• Allow adequate rest between stimulating events• Use labels to cue or remind the person• Increase the safety of the environment by equipping doors and gates with locks, and removing guns and other weapons• Reduce risk of fires by installing extra smoke alarms and controlling access to the stove• Use lighting to reduce confusion and restlessness at night

Helpful hints to prevent agitation

Create a calm environment: remove stressors, triggers or danger; move the person to a safer or quieter place; change expectations; offer a security object, rest or privacy; provide an opportunity for exercise; develop soothing rituals; and use gentle reminders.

Avoid environmental triggers: noise, glare, insecure space, and too much background distraction, including television.

Monitor personal comfort: check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation; ensure a comfortable temperature; be sensitive to fears and frustration with expressing what is wanted.

Helpful hints when a person becomes agitated

Do: Back off and ask permission; use calm, positive statements; reassure; slow down; add light; offer guided choices between two options; focus on pleasant events; offer simple exercise options, try to limit stimulation.

Say: May I help you? Do you have time to help me? You’re safe here. Everything is under control. I apologize. I’m sorry that you are upset. I know it’s hard. I will stay with you until you feel better.

Do not: Raise voice; show alarm or offense; corner, crowd, restrain, demand, force or confront; rush or criticize; ignore; argue, reason, or explain; shame or condescend; or make sudden movements out of the person’s view.

Medications to treat behavioral symptoms

Medications can be effective in some situations, but they must be used carefully and are most effective when combined with non-drug approaches. Medications should target specific symptoms so their effect can be monitored. In general, it is best to start with a low dose of a single drug. Effective treatment of one core symptom may some-times help relieve other symptoms. Thoughtful choice of a drug may also maximize its benefit. For example, some antidepressants may also help people sleep better.

Individuals taking medication for behavioral symptoms must be closely monitored. People with dementia are susceptible to serious side effects, including a slightly increased risk of death from antipsychotic medications. Risk and potential benefits of a drug should be carefully analyzed for any individual.

Some examples of medications commonly used to treat behavioral and psychiatric dementia symptoms are discussed in the following sections. These lists do not include every drug used for these purposes. Doctors base their choice of medication on many factors, including the underlying cause of dementia and an individual’s symptoms, living situation, caregiving arrangement, and coexisting health conditions.

When considering use of medications, it is important to understand that no drugs are specifically approved by the U.S. Food and Drug Administration (FDA) to treat behavioral and psychiatric dementia symptoms. Many of the examples discussed here represent “off label” use, widely accepted medical practice in which a physician may prescribe a drug for a different purpose than the ones for which it is approved.

Antidepressant medications for low mood and irritability include: citalopram (Celexa); fluoxetine(Prozac); paroxetine (Paxil); sertraline (Zoloft); andtrazodone (Desyrel).Antipsychotic medications for hallucinations, delusions, aggression, agitation and uncooperativeness include:

• Newer “atypical” agents such as aripiprazole(Abilify); olanzapine (Zyprexa); quetiapine(Seroquel); risperidone (Risperdal);and ziprasidone (Geodon)

• Older first-generation drugs such as haloperidol(Haldol)

The decision to use an antipsychotic drug needs to be considered with special care. Recent studies have shown that these drugs are associated with a slightly increased risk of death in older adults with dementia. The FDA has labeled the drugs with a warning about this risk and a reminder that they are not approved to treat dementia symptoms.

To maximize the chances of effectiveness, the choice of particular drug, how long it should be used, and when it should be discontinued all need to be carefully tailored to an individual’s symptoms and circumstances. The underlying cause of a person’s dementia may also influence the selection of a drug. For example, it is generally considered inadvisable for individuals with dementia with Lewy bodies(DLB) to take antipsychotic drugs.

Although antipsychotics are among the most frequently used medications for treating agitation, some physicians may prescribe an anticonvulsant/mood stabilizer, such asdivalproex (Depakote), for hostility or aggression.

Many experts recommend that use of drugs to treat agitation, aggression, hallucinations and delusions in persons with dementia be managed by a physician with experience and interest in this area.

Anti-anxiety drugs for anxiety, restlessness, verbally disruptive behavior and resistance include:

• Drugs such as lorazepam (Ativan) and oxazepam(Serax) for short-term treatment of acute symptoms

• Antidepressants may be used for longer-term treatment

Medications for sleep problems: Some medications are approved specifically by the U.S. Food and Drug Administration (FDA) as “sleeping pills.” Most physicians tend to avoid prescribing “sleeping pills” for older adults with dementia, since in this group these drugs may have serious side effects, including incontinence, problems with balance, falls or increased agitation. One widely used alternative is the antidepressant trazodone (Desyrel), which tends to make people sleepy. Anti-anxiety medications are also sometimes used.

Physicians also recommend that individuals with dementia avoid over-the-counter sleep remedies. The active ingredient in many of these preparations is diphenhydramine(Benadryl), an antihistamine that tends to make people feel drowsy. Diphenhydramine further suppresses the activity of one of the main brain cell messenger chemicals whose activity is reduced by Alzheimer’s disease. Examples of over-the-counter sleep aids containing diphenhydraminethat should be avoided include Compoz, Nytol, Sominexand Unisom. Diphenhydramine is also an ingredient in many “nighttime” or “PM” versions of popular pain relievers and cold and sinus remedies.

For more information about Alzheimer research, treatment and supportive care, please contact the Alzheimer’s Association.

24/7 Helpline 1.800.272.3900
TDD Access 312.335.8882
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Fact sheet updated Feb. 2, 2007