Cognitive and neuropsychiatric impairments in Alzheimer's disease: current treatment strategies.

This update on Alzheimer's disease (AD) discusses treatment strategies for cognitive and neuropsychiatric symptoms (such as agitation, psychosis, anxiety, and depression) common in this illness, emphasizing in particular nonpharmacologic strategies such as cognitive interventions, physical exercise, and psychotherapy. We provide an overview of cognitive enhancers and their combination strategies and medications commonly used for treatment of neuropsychiatric symptoms in AD. Finally, we give recommendations for providing support to caregivers and suggest how to identify caregiver/patient pairs most in need of intensive dementia care services.

Common psychiatric problems in cognitively impaired older patients: causes and management.

Although dementias are defined by their cognitive and functional deficits, psychiatric problems are common, contribute to patient distress and caregiver burden, and precipitate institutionalization. Successful treatment involves understanding that physiologic, psychological, and environmental factors can contribute to the development of these symptoms. By carefully assessing each of these factors, clinicians can individualize treatment and flexibly use nonpharmacologic and pharmacologic approaches tailored to patients and the context of care. Although there exist limitations to many treatment options, clinicians can still adapt current knowledge to develop a multifaceted treatment approach that improves the quality of life for patients and their caregivers.

Propranolol for disruptive behaviors in nursing home residents with probable or possible Alzheimer disease: a placebo-controlled study.

OBJECTIVE: Enhanced behavioral responsiveness to central nervous system (CNS) norepinephrine (NE) in Alzheimer disease (AD) may contribute to the pathophysiology of disruptive behaviors such as aggression, uncooperativeness with necessary care, irritability, and pressured pacing. We evaluated the efficacy of the beta-adrenergic antagonist propranolol for treatment-resistant disruptive behaviors and overall behavioral status in nursing home residents with probable or possible AD. METHODS: Thirty-one subjects (age 85 +/- 8 [SD]) with probable or possible AD and persistent disruptive behaviors that interfered with necessary care were randomized to propranolol (n = 17) or placebo (n = 14) in a double-blind study. Stable doses of previously prescribed psychotropics were maintained at pre-study dose during the study. Following a propranolol or placebo dose titration period of up to 9 days (per a dosing algorithm), subjects were maintained on maximum achieved dose for 6 weeks. Primary outcome measures were the Neuropsychiatric Inventory (NPI) and the Clinical Global Impression of Change (CGIC). RESULTS: Propranolol augmentation (mean achieved dose 106 +/- 38 mg/d) was significantly more effective than placebo for improving overall behavioral status on the total NPI score and CGIC. Improvement in individual NPI items within propranolol subjects was significant only for "agitation/aggression" and "anxiety," and reached borderline statistical significance favoring propranolol over placebo only for "agitation/aggression." Pressured pacing and irritability did not appear responsive to propranolol. In propranolol subjects rated "moderately improved" or "markedly improved" on the CGIC at the end of the double-blind study phase, improvement of overall behavioral status had diminished substantially after 6 months of open-label propranolol treatment. CONCLUSION: Short-term propranolol augmentation treatment appeared modestly effective and well tolerated for overall behavioral status in nursing home residents with probable or possible AD complicated by disruptive behaviors. Propranolol may be helpful specifically for aggression and uncooperativeness (the behaviors assessed by the NPI "agitation/aggressiveness" item). However, the usefulness of propranolol in this very old and frail population was limited by the high frequency of relative contraindications to beta-adrenergic antagonist treatment and diminution of initial behavioral improvements over time.

Identifying undiagnosed dementia in residential care veterans: comparing telemedicine to in-person clinical examination.

BACKGROUND: Dementia is a common but frequently undiagnosed problem in aging. Barriers to early diagnosis include a lack of routine screening for dementia and a lack of access to specialty consultative services. We conducted a pilot study to see if telemedicine could provide reliable, accurate geriatric consultative services to evaluate patients for dementia who were residing at remote sites. METHODS: This was a prospective cohort study that compared the diagnostic reliability of telemedicine to an in-person examination for dementia. Eligible subjects were residents of a Washington State Veterans' Home, age 60 years or older, with no prior diagnosis of dementia. Eligible subjects were screened for dementia using the 7-Minute Screen. Veterans who screened positive and consented to participate in the study received an in-person neuropsychiatric evaluation at baseline, and then both telemedicine and in-person examinations for dementia conducted by experienced geriatric psychiatrists. The accuracy of the telemedicine diagnosis was estimated by comparing it to the diagnosis from the clinical examination. Three geriatric psychiatrists who were blinded to the results of the clinical examination conducted the telemedicine and in-person examinations. We also assessed attitudes of the subjects and geriatric psychiatrists towards the telemedicine sessions. RESULTS: Eighteen of 85 subjects screened were 'positive' for dementia on the 7 Minute Screen. Of these, 16 consented to participate in the telemedicine study. Twelve of the 16 subjects were subsequently diagnosed with dementia by the telemedicine examination. The telemedicine diagnoses were in 100% agreement with the diagnoses from the in-person clinical examinations. Moreover, the subjects reported a high degree of satisfaction with the telemedicine experience and that they would like to have further care through telemedicine in the future. The geriatric psychiatrists reported technical difficulties with the audio-visual quality of telemedicine in the initial phases of the project that resolved as familiarity with the telemedicine equipment increased. None of these problems had an adverse impact on the diagnostic accuracy of telemedicine. CONCLUSIONS: We found that telemedicine was as accurate as an in-person clinical examination in establishing the diagnosis of dementia. In addition, subjects reported a high degree of satisfaction with telemedicine and a willingness to participate in telemedicine clinical care in the future. Given the large increase in the aging population and the shortage of geriatric psychiatrists nationally, it appears that telemedicine may be a promising means to expand the availability of geriatric psychiatric consultation to remote areas.