Managing Behavioral and Psychiatric Symptoms

Learn about behavioral and psychiatric symptoms of Alzheimer's disease; how they are diagnosed and drug and non-drug treatments.

What are the 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 individuals with Alzheimer's. In the 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 aggression, 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 underlying 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 treatments for Alzheimer's

The two major types of treatment for behavioral and psychiatric symptoms are non-drug interventions and prescription medications. Non-drug interventions should be tried first. In general, steps to developing non-drug alzheimer's management strategies include

1. identifying the symptom
2. understanding its cause
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
• equip doors and gates with safety locks
• remove guns
• use lighting to reduce confusion and restlessness at night

Alzheimer's 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. 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. Examples of medications commonly used to treat behavioral and psychiatric symptoms include the following:

• Antidepressant medications for low mood and irritability: citalopram (Celexa); fluoxetine (Prozac); paroxetine (Paxil); and .
• Anti-anxiety drugs for anxiety, restlessness, or verbally disruptive behavior and resistance: lorazepam (Ativan) and oxazepam (Serax).
• Antipsychotic medications for hallucinations, delusions, aggression, agitation and uncooperativeness: aripiprazole (Abilify); clozapine (Clozaril); olanzapine (Zyprexa); quetiapine (Seroquel); risperidone (Risperdal); and ziprasidone (Geodon).

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

Sedative medications, which are used to treat sleep problems, may cause incontinence, instability, falls or increased agitation. These drugs must be used with caution, and caregivers need to be aware of the possible side effects.

Helpful hints during an episode of agitation

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, or limit stimulation

Say:

• May I help you?
• Do you have time to help me?Managing Behavioral and Psychiatric Symptoms
• 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
• make sudden movements out of the person's view

Helpful hints to prevent agitation

• Create a calm environment: remove stressors, triggers or danger; move person to a safer or quieter place; change expectations; offer security object, rest or privacy; limit caffeine use; provide 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.

Sources:

• Manju T. Beier, Pharm.D., FASCP, Treatment Strategies for the Behavioral Symptoms of Alzheimer's Disease, Pharmacotherapy. 2007;27(3):399-411
• Alzheimer's Association