"Behavior Disorders of Dementia: Recognition and Treatment" (My Synopsis)

My synopsis of "Behavior Disorders of Dementia: Recognition and Treatment"
ABI V. RAYNER, M.D., M.P.H., JAMES G. O’BRIEN, M.D., and BEN SCHOENBACHLER, M.D., University of Louisville School of Medicine, Louisville, Kentucky
Am Fam Physician. 2006 Feb 15;73(4):647-652.
http://www.aafp.org/afp/2006/0215/p647.pdf


     Dementia can lead to cognitive and psychotic features. Cognitive features include agitation, wandering, and aggression. Hallucinations, delusions, and delusional misidentifications are examples of psychotic features. The psychotic features are more of a burden to the caregiver than the cognitive ones. The first step in management is to find and remove any precipitating factors (drugs, alcohol, caffeine, hunger, or thirst). The caregiver should have a good understanding about the disease and the manifestations. It is important to create a safe environment for the patient, by removing weapons, as well as furniture that may promote tripping or falls. There are several behavioral techniques that should be used when dealing with dementia patients. Trying to reason with dementia patients is not as effective as trying to distract them. Closed-ended questions are less confusing than opened-ending questions. Rather than responding to the content of what the patient is saying, it may be better to respond to the emotional content (validation therapy). Recounting pleasurable memories and experiences is known as reminiscence therapy.  Setting a daily schedule for these patients, like having meals at the same time each day, will provide beneficial consistency for these patients.
     With all medications for the elderly, it is better to start with one medication at a time, and with the lowest dose possible. First line agents for psychotic symptoms is atypical antipsychotics (clozapine, olanzapine, quetiapine and risperidone). They are better tolerated and cause less extrapyramidal side effects (especially quetiapine) than typical antipsychotics. Patients on atypicals may have exacerbations of tremor, rigidity, dystonia, and dyskinesia. These medications can be sedating, so they are better given at night.
     The typical antipsychotic used to manged delirium and acute agitation is haloperidol (olanzapine is the atypical antipsychotic that works well with acute agitation). The most common side effect is prolonged rigidity.
     Anticonvulsants/ mood stabilizers (depakote and carbamazepine) are second line agents for dementia. The narrow therapeutic window of carbamazepine somewhat limits its use. Sedation is common with these medications.
     The acetylcholinesterase inhibitors are donepezil, galantamine, and rivastigmine. These medications may delay cognitive loss in dementia. They are not effective for psychosis and thus are used as adjunctive therapy.
     The two anxiolytics are buspirone and lorazepam. Although these are commonly used in dementia, they are not first line therapy and there is little research to support its usage. They are specifically used in patients with acute agitation. Patients with lewy body syndrome may worsen when these medications are used.