Alzheimer’s disease is a chronic, progressive neurodegenerative brain disorder that affects patient’s memory, language, and judgment, decision making, planning and organizing. Alzheimer’s disease (AD) remains the most common cause of dementia. There are currently 5.3 million Americans affected by the disease, and as the number of aging population increases without a disease modifying treatment, it is projected to be 15 million by 2050. AD is a complex disease; hence the treatment can at times be complicated and often challenging to the treating physicians. Successful treatment of patients with AD requires a thorough understanding of the patient and the family dynamic. AD like any other chronic condition may have other medical and psychiatric comorbidities that need to be addressed. Treating the AD with anti-dementia drugs is a small part of the comprehensive management of AD. The discussion of medical co-morbidities are beyond the scope of this article, however, the psychiatric co-morbidities such as depression, anxiety, delusions, hallucinations, agitation and aggression will be discussed. Some patients may have an undiagnosed personality disorder that resurfaces as the patient’s ability to compensate diminishes. The physicians who treat patients with AD need to keep in mind that the management of this disease is more than just memory medication. Even among the patients with AD the presentation and the course of the disease varies. Therefore the successful management of AD requires a comprehensive approach not only to the memory, but also the co-morbidities.
Depression affects 20% to 32% of patients with dementia, though more prevalent in vascular dementia as compared to AD. The diagnosis and treatment of depression in patients with dementia is quite challenging as it can be an early manifestation of dementia or cause of the dementia called pseudodementia. The depression can fluctuate and the presentation may vary, such as difficulty with attention and focusing, apathy, anxiety, and agitation as opposed to feeling of guilt, insomnia, hypersomnia or suicidality. There may also exist an undiagnosed bipolar depression that needs attention as the treatment is somewhat different. There are several scales to assess depression in patients with dementia, such as Geriatric depression scale, Hamilton depression and Cornell scale for depression. The treatment of depression in dementia include; pharmacotherapy and psychosocial modalities, although ECT has been used for severe cases. The SSRIs remain the mainstay of treatments and have a better safety profile as these patients are prone to medication side effects. In the case of bipolar depression, treatment with mood stabilizers may improve the patient’s mood. The psychosocial stimulation, such as supportive therapy, focusing on positive aspects of life, happy memories, enjoyable experiences, and previous accomplishments are effective non-pharmacological approach to depression.
Anxiety affects 20% of patients with dementia. In the initial stages of the disease is the fear of losing control. Generalized anxiety disorder occurs in 5% of patients with AD. As the disease progresses anxiety level can fluctuate depending on the living situation and the patient’s support structure. Patients may present with restlessness, irritability, fatigue and sleep disturbance. Anxiety like depression can be measured using standard scales such as Worry scale which is a self report in mild dementia, and Rating Anxiety in Dementia relies on all available data to rate the anxiety. This includes the caregiver report and patient observation. Treatment of anxiety includes social intervention such as milieu therapy, addressing patient’s specific stressors or environmental factors, and pharmacotherapy, although this approach needs to be addressed with extreme caution as patients with dementia are sensitive to tranquilizers. The initial approach should be a trial of SSRI antidepressants, as most drugs in this class also treat anxiety successfully.
Delusions and hallucinations have been present in 15%- 20% of patients with dementia, and increase with the disease progression. Hospital induced psychosis such as delirium, during a hospital stay secondary to urinary tract infection or pneumonia, could be the first manifestation of dementia in elderly population. Paranoid delusion of intruders and missing personal possession are common. Some patients do not recognize family members or their own home, and some report seeing dead relatives, animals and children in the house as part of visual hallucinations. The psychotic symptoms are often accompanied by agitation and aggressive behavior. The psychosis is often elicited from the patient or caregiver and by the use of scales such as BEHAVE-AD, dementia psychosis scale or NPI (Neuropsychiatric Interview). The treatment of psychosis in dementia is quite challenging as the new data reports increased risk of cardiovascular related death in elderly patients with dementia. As long as the psychosis is not disruptive to the patient and family, it does not have to be treated. Behavioral and environmental interventions, such as avoiding confrontation, argument, gentle touching, and environmental modifications are the first line of therapy, and should be employed in combination with psychopharmalogical therapy. This requires a tremendous patience on the part of the care giver as it tends to occur quite frequently.
In the cases where some form of antipsychotic treatment must be used for patient and family safety, the newer antipsychotic drugs are recommended as these drugs have a better side effect profile. The patients and their family should be informed of the black box warnings related to antipsychotic drugs. It is also important to recognize depression induced psychosis which may improve by treating the patients with antidepressants such as SSRIs. The bipolar depression can also present with psychosis during manic episodes. As mentioned earlier psychosis could be a manifestation of an underlying medical condition that needs a thorough investigation.
AGITATION AND AGGRESSION
Among patients with dementia, 27% exhibit agitation and/or aggressive behavior. There are two categories of agitation/aggression in dementia. One with psychosis such as delusions and hallucination and the other without psychosis. Agitation/Aggression should be thoroughly investigated as it can signal an underlying medical condition or a patient need that cannot be properly communicated, such as hunger, thirst, pain or a need for toileting. It can also be secondary to the underlying dementia, depression or anxiety. These symptoms are particularly important as it can be a concern for patient and/or caregiver safety. Patients with severe agitation are often angry with others, especially with the care giver. They often resist help with basic activities, such as showering, getting dressed or toileting. Patients with dementia often get agitated in a new environment such as hospital a new facility, new caregivers and drug side effects. For example certain tranquilizers and anticholinergic drugs that are used for bladder control can cause agitation in these patients. So the cause should be sought, and addressed first. The environmental modification and supportive therapy is the mainstay of the treatment. Physical restraints should be the last resort and used only in cases where the patient is a danger to himself or others. The medications such as antidepressants, mood stabilizes, and if needed, antipsychotics can be used, again with special attention to the potential side effects. One important psychiatric comorbidity that is often overlooked by physicians caring for patients with dementia is undiagnosed personality disorder that can explain many of the behavioral disturbances that accompany a difficult patient. The patients with personality disorder pose a real challenge to the treating physician, as the patients are not aware of their illness. Unfortunately the diagnosis of this co-morbidity is quite difficult and the treatment almost impossible.
The psychiatric co-morbidities in patients with AD could be either part of the dementia or an undiagnosed condition. In either case it is the second most important issue that needs to be addressed and treated. It is important to keep in mind that the treatment of dementia is not just memory treatment, although that has been the main focus. The successful management of patients with dementia in general, and Alzheimer’s dementia in particular, is treating all symptoms of disease.
The physicians who treat patients with AD need to keep in mind that the management of this disease is more than just memory medication.
Delusions and hallucinations have been present in 15%-20% of patients with dementia, and increase with the disease progression.
Alzheimer’s Disease Co-morbidities
by M. Reza Bolouri, M.D.
This article first appeared in the Spring-Summer issue of the GCM Journal, a publication of the National Association of Professional Geriatric Care Managers, www.caremanager.org.