Psychiatric Management of Non-Cognitive Symptoms

Psychiatric and behavioural problems are present in up to 90% of patients with dementia.[i]

Non-cognitive symptoms of dementia tend to evolve over time, so regular monitoring allows adaptation of treatment strategies to current individual needs. For example, among the behavioural disturbances common in Alzheimer disease, depression is more common early in the illness, while delusions and hallucinations are more common in the middle and later stages. Behavioural issues to be addressed include major depression and other depressive syndromes, suicidal ideation or behaviour, hallucinations, delusions, agitation, aggressive behavior, disinhibition, anxiety, apathy, and sleep disturbances.[ii]

Early intervention is important since psychiatric symptoms can respond to treatment more readily than cognitive and functional deficits.26 Table 5. shows the behavioural clusters manifested in AD and relevant classes of medications for intervention.26

Table 5: Behavioural Clusters Matched with Potentially Relevant Classes of Medications26

Behaviour	Agent
Agitation/aggression	Antipsychotics,anticonvulsants, antidepressants, anxiolytics
Anxiety	Antidepressants, anxiolytics, anticonvulsants
Apathy	Antidepressants, stimulants
Disturbed effect/mood	Antidepressants, anticonvulsants
Altered ideation/perception	Antispsychotics
Vegetative features	Antidepressants, anxiolytics, stimulants

§   There is sufficient evidence from randomized controlled trials to support the use of both traditional and atypical antipsychotics for the management of agitation and psychosis in dementia. Of the two classes atypical antipsychotics appear to be better tolerated compared to traditional antipsychotics.20^{, 27}

§   There is evidence that SSRIs (selective serotonin reuptake inhibitors) antidepressants may be administered and are better tolerated than other antidepressants.

The American Academy of neurology practice guidelines conducted an in-depth review of pharmacological therapies for non-cognitive symptoms in dementia. The expert panel conclude that most studies in this area focus on mixed populations with dementia.

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[i] Tariot P. Medical Management of Advanced Dementia. J Am Geriatr Soc. 2003: 51: S305-S313.

[ii] http://www.psych.org/psych_pract/treatg/pg/pg_dementia_3.cfm#c. American Psychiatric Association. Practice guidelines for the Treatment of Alzheimer’s Disease and Other Dementias of Late Life. Last Accessed April 1, 2004.