Journal of Geriatric Psychiatry and Neurology

Behavioral and psychiatric symptoms frequently accompany the cognitive deterioration of dementia occurring in up to 80% of both community-based and nursing home patients. In Alzheimer's disease (AD), behavioral complications may develop at any stage of the disease process and tend to follow a more unpredictable course than the core cognitive symptoms. Over the past 15 years, our knowledge of the biologic and neurochemical basis of dementia, and of AD in particular, has increased significantly. Great emphasis has been placed on the cholinergic system abnormalities in the context of the cognitive impairment in AD and on the psychopharmalogic enhancement of cholinergic transmission in AD. However deficits in other neurotransmitter systems, such as the noradrenergic, serotonergic, and dopaminergic systems, also occur and may contribute to the core cognitive symptoms of AD. More recently, there has been increased interest in the biologic and neurochemical basis of behavioral and psychiatric disturbances in dementia. This article reviews the evidence for biologic and neurochemical correlates of psychosis and agitation in dementia, and discusses the treatment implications for these findings. (J Geriatr Psychiatry Neurol 1995; 8(suppl 1):S2-S7).

Selecting outcome measures that are both psychometrically sound and sensitive to change is a very important aspect of clinical outcome research. A variety of measures have been introduced in recent years to assess behavioral complications in dementia, but few have been adequately tested in clinical trials. This article provides a discussion of factors to consider in selecting measures, including psychometrics, item content, assessment source, and sensitivity to change. A review of behavioral and psychiatric measures for dementia patients is provided, including measures of general behavioral disturbance, and measures specifically developed for agitation and depression. Each measure's psychometric characteristics, prior use with demented patients, and strengths and weaknesses with regard to treatment outcome research is summarized. The importance of linking measures to the investigators' hypotheses is discussed, along with recommendations for evaluating and selecting outcome measures depending on the needs of the specific investigation. (J Geriatr Psychiatry Neurol 1995; 8(suppl 1):S8-S17).

Neuroleptics remain the mainstay for the treatment of behavioral disturbance and psychotic symptoms in demented patients. The limited available data suggest that low-dose neuroleptics are significantly more efficacious than placebo, though the magnitude of the effect is moderate in most published studies. Demented patients are particularly prone to neuroleptic side effects, and individualized dose titration may be necessary to achieve the optimal trade-off between efficacy and side effects. Target behavioral symptoms and side effects, including effects on cognition and activities of daily life, should be identified and assessed serially during neuroleptic treatment. The choice of neuroleptic depends more on likely side effects than differential efficacy, and non-response or intolerable side effects should lead to dose adjustment or a switch to an alternative class of neuroleptic (or an alternative type of medication). Further studies of optimal neuroleptic dosage, the optimal duration of continuation neuroleptic treatment, and placebo-controlled studies comparing neuroleptics to other classes of medications are needed. (J Geriatr Psychiatry Neurol 1995; 8(suppl 1):S18-S27).

Studies have shown that the vast majority of patients with dementia experience some psychopathologic symptoms during the course of their illness. Symptoms of this nature, which can include frightening hallucinations or anxiety of phobic proportions, are subjectively distressing and can lead both to unsafe or violent situations as well as to the preventable use of inappropriate medication, physical restraint, and frequently to institutionalization. These psychopathologic manifestations of dementia often prove to be a burden on family, caregivers, and the health care system as well. This article presents an overview of the assessment and management of agitation as it relates to the severity of dementia symptoms and cognitive deterioration. Specifically, the use of anticonvulsant and other non-neuroleptic therapies is examined. (J Geriatr Psychiatry Neurol 1995; 8(suppl 1):S28-S39).

Research describing wide prevalence variation of Alzheimer's disease (AD) and comorbid depression is explained in light of subsyndromal depressions, the use of standardized diagnostic instruments and procedures, and the subcortical and cortical components of mood. There appear to be several "depressions" of AD. Against this backdrop, double-blind, placebo-controlled studies of antidepressant use in AD are reviewed and methodologic problems identified. Evidence for efficacy in controlled trials is weak, but open-label trials are, as expected, more encouraging. The potential efficacy of new agents for the depressions of AD receive comment. A heuristic model makes use of the conclusions developed, the stage of illness, and a preliminary classification scheme for the depressions of AD; this model provides a rational basis for thinking about medication selection for AD depressions. Clinical decisions are illustrated. (J Geriatr Psychiatry Neurol 1995; 8(suppl 1):S40-S51).