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Safety issues should be
addressed at every evaluation.
Families should be advised about the possibility of
accidents (e.g., fires while cooking), difficulties coping with
household emergencies, and wandering.
Family members should also be advised to determine whether the
patient is handling finances appropriately and to consider taking
over the paying of bills and other responsibilities.
At this stage, nearly all patients should not drive,
and families should be counseled to undertake measures to prevent
patients from driving, as many patients lack insight into the risks.
Evidence suggests that the
combination is more likely to improve cognitive function or delay
symptom progression than a cholinesterase inhibitor alone.
Treatment of psychosis and
agitation can increase the comfort and safety of the patient and
ease care by the family and other caregivers.
Consideration of the risks and benefits of treatment,
discussion of these with the patient and caregivers, and documentation
of these discussions should precede treatment.
If psychotic symptoms cause minimal distress to the
patient and are unaccompanied by agitation or combativeness, they
are best treated with environmental measures, including reassurance and redirection.
If the symptoms do cause significant distress or are
associated with behavior that may place the patient or others at
risk, treatment with low doses of antipsychotic medication is indicated
in addition to nonpharmacological interventions. Treatment with
an antipsychotic medication is also indicated if a patient is agitated or
combative in the absence of psychosis, because antipsychotics have
the most support in the literature. However, the potential benefits
of antipsychotic medications need to be weighed against the potential
for increased mortality when they are used by individuals with dementia.
When antipsychotics are ineffective, carbamazepine,
valproate, or an SSRI may be used in a careful therapeutic trial.
If behavioral symptoms are limited to specific times or settings
(e.g., a diagnostic study), or if other approaches fail, a low-dose
benzodiazepine may prove useful, although side effects in the elderly can
be problematic. Although mood stabilizers and SSRIs are commonly
used in clinical practice to treat agitation, delusions, and aggression,
they have not been consistently shown to be effective in treating
these symptoms, nor is there substantial evidence for their safety.
Thus, in making decisions about treatment, these agents should not
be seen as having improved safety or comparable efficacy compared
with antipsychotic medications.
As a dementing illness evolves, psychosis and agitation
may wax and wane or may change in character. As a result, the continued use
of any intervention for behavioral disturbances or psychosis must
be evaluated and justified on an ongoing basis.