ABSTRACT
When psychological and behavioral disorders of Alzheimer's disease appear suddenly, somatic, iatrogenic and reactive or relational psychological causes must be ruled out or treated before concluding that the cause is lesional. Non-pharmacological interventions should be privileged for the prevention and management of behavioral manifestations of mild to moderate intensity: psychological support of the patient (short therapies), training the caregiver, work on daily habits, reorganization of the home, behavioral measures against apathy and especially agitation, rehabilitation strategies, and therapy involving music, light, aromas, etc. Pharmacological therapies are only moderately effective in these disorders. They must be targeted and follow a sequence of prescription that maximizes tolerance and distinguishes treatment of acute and chronic states. Anticholinesterase agents may be useful in this domain to prevent or ease some symptoms (especially apathy). The efficacy of memantine must be confirmed by additional data. Some selective serotonin reuptake inhibitors agents may be useful not only in depression but also anxiety, emotional disturbances, irritability and compulsiveness. Atypical neuroleptics are better tolerated than the classic ones. They are most effective in this context but must be reserved for specific indications and limited in time because of the increased risk of stroke. Other psychotropics (benzodiazepines, carbamates, antiepileptics) should be used cautiously in this context.
Subject(s)
Alzheimer Disease/complications , Cognition Disorders/therapy , Mental Disorders/therapy , Activities of Daily Living , Alzheimer Disease/drug therapy , Alzheimer Disease/psychology , Alzheimer Disease/rehabilitation , Alzheimer Disease/therapy , Anti-Anxiety Agents/therapeutic use , Anticonvulsants/therapeutic use , Antidepressive Agents/therapeutic use , Antipsychotic Agents/therapeutic use , Cholinesterase Inhibitors/therapeutic use , Cognition Disorders/diagnosis , Cognition Disorders/drug therapy , Cognition Disorders/etiology , Home Nursing , Humans , Hypnotics and Sedatives/therapeutic use , Institutionalization , Interpersonal Relations , Mental Disorders/diagnosis , Mental Disorders/drug therapy , Mental Disorders/etiology , Nootropic Agents/therapeutic use , Psychotherapy , Selective Serotonin Reuptake Inhibitors/therapeutic useABSTRACT
Although Alzheimer's disease has long been considered mainly a cognitive disorder, behavioral and psychological symptoms are present from its onset and at all the stages of the disease in most patients. They must be identified from the beginning because they orient the diagnosis. They include affective and emotional disorders, delusions and hallucinations, disorders of instinctual behavior and behavioral problems. The best tool for assessing them is the Neuropsychiatric Inventory (NPI). They are generally related to neurobiological aspects of the disease but may, especially when acute, have multiple etiologies: somatic, iatrogenic, psychological and environmental. They condition the course of the disease. As a source of suffering and reduced quality of the life and as the primary cause of distress for the caregivers and hence of hospitalization and institutionalization, they increase the costs of care. The challenge today is to learn more about them and thus improve their treatment and especially their prevention.
Subject(s)
Alzheimer Disease/diagnosis , Cognition Disorders/etiology , Mental Disorders/etiology , Affective Symptoms/diagnosis , Affective Symptoms/etiology , Alzheimer Disease/psychology , Cognition Disorders/diagnosis , Early Diagnosis , Emotions , Hallucinations/diagnosis , Hallucinations/etiology , Humans , Inhibition, Psychological , Mental Disorders/diagnosis , Neuropsychological Tests , Physical Examination , Psychological Tests , Psychotic Disorders/diagnosis , Psychotic Disorders/etiology , Quality of Life , Sleep Disorders, Intrinsic/diagnosis , Sleep Disorders, Intrinsic/etiology , Surveys and QuestionnairesABSTRACT
Behavioral and Psychological Symptoms in Dementia (BPSD) are, beside cognitive disorders, major features of Alzheimer's disease and related disorders. Diagnosis is important to enhance our knowledge of the pathophysiology of dementia and of their functional consequences for patients and caregivers. Pharmacological and non-pharmacological management of dementia depends to a large extent on the presence of BPSD. A committee of geriatricians, neurologists and psychiatrists specialized in dementia (THEMA 2) has promoted an epidemiological, diagnostic and therapeutic update in this field. This work was based on the BPSD Consensus Conference Report edited in 2000 by the International Psychogeriatric Association. This report was updated with the most recent literature reports, and was adapted to the French environment. This paper is a synthesis of this meeting, validated and corrected by the entire Thema 2 group.
Subject(s)
Dementia/diagnosis , Dementia/psychology , Aged , Behavior , Dementia/therapy , France , Humans , Nootropic Agents/therapeutic use , Psychotropic Drugs/therapeutic use , Terminology as TopicABSTRACT
EXTENSIVE HETEROGENEITY: The nosology of delusional disorders in the elderly is still debatable. The nosology varies greatly from that of the younger adults. It is heterogeneous because of the age at onset of the symptomatology, etiology and behavioural consequences (agitation, aggressiveness) of the delusion. TWO DISTINCT CONTEXTS: We can distinguish between the long term, old, psychoses and the delusions having occurred later in life (after the age of 60). The outcome of the former is still unknown; but often progresses towards the reduction in symptomatology. In the latter, various etiologies are observed with, primarily, delusions associated with dementia, followed by thymus delusions, schizophrenic or non-schizophrenic psychoses, delusions related to cerebral-vascular disorders or sensorial dysafferentation. It is important to underline the fact that any de novo delusion occurring after the age of 65 must evoke an underlying deterioration. ENHANCING FACTORS: In addition to a genetic predisposition suspected in certain cases, vulnerability factors are usually found in the context of age: somatic comorbidity, loneliness, sensory deficiencies, cognitive impairment, polymedication, and addict attitude. FROM A DIAGNOSTIC POINT OF VIEW: The differential diagnosis is essentially made with mental confusion. The evaluation calls upon scales, either specific to the psychosis and similar to those used in adults (SANSS, PANSS, PDI), or global and intended for psychological dementia and behavioural disorders (NPI).
Subject(s)
Aged , Delirium/etiology , Adult , Age Distribution , Age Factors , Age of Onset , Comorbidity , Delirium/diagnosis , Delirium/epidemiology , Diagnosis, Differential , Female , Genetic Predisposition to Disease/genetics , Geriatric Assessment , Humans , Male , Mental Status Schedule , Psychiatric Status Rating Scales , Risk FactorsABSTRACT
THE MAJOR THERAPEUTIC TRENDS: The treatment of psychosis in late life depends on the etiology of the delusion but also on its behavioral consequences (agitation, aggressiveness). We distinguish between the treatment of long term old psychosis and delusions occurring late in life (after the age of 60). FOR THE OLD PSYCHOSES: The reduction in the symptomatology often permits a reduction in the doses and the relay to atypical neuroleptics with improved tolerance. FOR DELUSIONS OCCURRING LATE IN LIFE: The treatment will be adjusted to the etiology of the delusion: delirious states associated with dementia, thymus delusion, schizophrenic or non-schizophrenic psychosis, delusion related to cerebral-vascular disorders or to sensorial dysafferentation. One should note that emotional and delusional disorders are often concomitant in the elderly. THE TWO TREATMENT AXES: The first therapeutic element is non-pharmacological: reassurance or even brief psychotherapy, family counseling and prevention of enhancing, notably environmental, factors. The pharmacological element preferably includes atypical anti-psychotics, antidepressants in some cases together with anti-epileptics in cases of concomitant rebellious aggressiveness. In cases of dementia with cholinergic deficiency (Alzheimer, Lewy body dementia, mixed dementia) cholinesterase inhibitors have demonstrated their efficacy on the hallucinations. Advice for a pertinent strategy of action should be provided.
Subject(s)
Aged , Delirium/therapy , Age of Onset , Antidepressive Agents/therapeutic use , Antipsychotic Agents/therapeutic use , Cholinesterase Inhibitors/therapeutic use , Comorbidity , Counseling , Delirium/diagnosis , Delirium/etiology , Electroconvulsive Therapy , Family/psychology , Geriatric Assessment , Humans , Patient Selection , Psychotherapy, Brief , Social Support , Treatment OutcomeABSTRACT
The proportion of patients consulting pluridisciplinary memory clinics who present anxiety disorders varies with recruitment and referral practices but often exceeded 10p.100. Most of these subjects have an anxiety trait or stress-related generalized anxiety, often triggered by diagnosis of Alzheimer's disease in a close friend or relation. The consultant should play special attention to analyzing the complaint in order to disclose difficulties in attention, true "loss of memory" events, and any recent traumatic events. The psychometric examination is generally normal or evidences discrete frontal dysfunction. Other diagnoses should be ruled out: associated depression, iatrogenic effect, alcoholism, anxiety as a sign of a somatic disease. Management may include drugs, usually on a short term regimen. Short-term psychotherapy or group therapy may be helpful.
