Subscribe Now/Learn More
PsychiatryOnline subscription options offer access to the
DSM-5 library, books,
journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists
and mental health professionals with key resources for diagnosis, treatment, research,
and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org
or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).
Suggest pragmatic coping
strategies such as making lists, using a calendar, and avoiding
Consider referring the patient to health promotion activities
and recreation clubs.
Identify specific impairments and highlight remaining
Provide psychotherapeutic interventions for patients
struggling with the diagnosis.
Address caregiver well-being, driving, and legal and
financial issues, as already described.
These three cholinesterase
inhibitors are approved by the U.S. Food and Drug Administration
(FDA) for the treatment of the cognitive symptoms of mild to moderate
Alzheimer's disease and are commonly used.
Given the possible risks of long-term high-dose vitamin
E and selegiline and the minimal evidence for their benefit, they
are no longer recommended. Nonsteroidal anti-inflammatory agents, statin
medications, and estrogen supplementation have shown a lack of efficacy
and safety in placebo-controlled trials in patients with Alzheimer's
disease and therefore are not recommended.
A cholinesterase inhibitor should also be considered
for patients with mild to moderate dementia associated with Parkinson's
disease. Only rivastigmine has been FDA approved for this indication,
but there is no reason to believe the benefit is specific to rivastigmine.
A cholinesterase inhibitor can be considered for patients
with dementia with Lewy bodies.
The constructs of mild cognitive impairment and vascular
dementia are evolving and have ambiguous boundaries with Alzheimer's
disease. The efficacy and safety of cholinesterase inhibitors for
patients with these disorders is uncertain; therefore, no specific
recommendation can be made at this time, although individual patients
may benefit from these agents.
There is some evidence of the benefit of memantine in
mild Alzheimer's disease and very limited evidence of its
benefit in vascular dementia.
Patients may be interested in referrals to local research
centers for participation in clinical trials of experimental agents.
The best approach to diagnosing
depression co-occurring with dementia is not yet clear. In addition
to the symptoms outlined in DSM-IV-TR, irritability, social withdrawal,
and isolation may indicate depression needing treatment. Symptoms
may be unstable and fluctuate over time.
Conditions that may cause or contribute to depression
include other psychiatric disorders (e.g., alcohol or sedative-hypnotic dependence),
other neurologic problems (e.g., stroke, Parkinson's disease),
general medical problems (e.g., thyroid disease, cardiac disease,
cancer), and the use of certain medications (e.g., corticosteroids,
Depression may worsen cognitive
impairment associated with dementia. Therefore, one goal of treating
depression in dementia is to maximize cognitive functioning. Treatment
of depression may also reduce other neuropsychiatric symptoms associated
with depression such as aggression, anxiety, apathy, and psychosis.
Clinical consensus supports a trial of an antidepressant
to treat clinically significant, persistent depressed mood in patients
with dementia. Selective serotonin reuptake inhibitors (SSRIs) may be
preferred because they appear to be better tolerated than other
antidepressants. Alternative agents to SSRIs include but are not
limited to venlafaxine, mirtazapine, and bupropion.
Electroconvulsive therapy (ECT) may be considered for
patients with moderate to severe depression that is life-threatening
or refractory to other treatments.
Sleep problems have been
reported in 25%–50% of patients with
dementia. Major causes include physiological changes associated
with aging, pathological involvement of the suprachiasmatic nucleus,
the effects of co-occurring medical or psychiatric disorders or
medications, untreated pain, and poor sleep hygiene. Cholinesterase
inhibitors can also cause insomnia.
Some over-the-counter sleep medications (e.g., diphenhydramine)
can contribute to delirium and paradoxically worsen sleep. Thus,
it is important to ask if the patient is using over-the-counter or
herbal preparations to treat sleep disturbance and to recommend
discontinuance of diphenhydramine if it is being used.
Treatment goals include
decreasing the frequency and severity of insomnia, interrupted sleep,
and nocturnal confusion; increasing patient comfort; decreasing
disruption to families and caregivers; and decreasing nocturnal
wandering and nighttime accidents.
When sleep disturbance is an isolated problem, clinical
practice favors beginning with nonpharmacological approaches, such
as training caregivers in the importance of sleep hygiene, establishing
regular sleep and waking times, limiting daytime sleeping, avoiding
fluid intake in the evening, establishing calming bedtime rituals,
and providing adequate daytime physical and mental activities.
Underlying medical and psychiatric conditions that could
disturb sleep should be evaluated and treated. Medications that
could interfere with sleep should be adjusted if possible.
Pharmacological treatment should be instituted only
after other measures have been unsuccessful and the potential benefits
outweigh the risk of side effects. It is particularly important
to identify sleep apnea, which may affect 33%–70% of
patients with dementia. This condition is a relative contraindication
to the use of benzodiazepines or other agents that suppress respiratory
If another behavioral or neuropsychiatric condition
is present and medications used to treat that condition have sedative
properties, clinical practice favors prescribing that agent at bedtime, if
appropriate (e.g., an antidepressant with sedative properties, a
Pharmacological interventions include trazodone or a
non-benzodiazepine hypnotic such as zolpidem or zaleplon. Benzodiazepines
may be used but are generally recommended only for short-term sleep
problems because of the possibility of tolerance, daytime sleepiness,
rebound insomnia, worsening cognition, falls, disinhibition, and
delirium. Rebound insomnia and daytime sleepiness can occur with
any of these agents. Triazolam is not recommended for individuals
with dementia because of its association with amnesia.