Geriatric Psychiatrists List Do’s, Don’ts for Treating Behavioral Disturbances Associated with Dementia

Though there are no medicines approved by the Food and Drug Administration for the treatment of behavioral and psychological symptoms of dementia (BPSD), the use of pharmacological therapy is common in the management of behavioral disturbances in those with neurocognitive disorder—increasing the risk that prescribers treat patients with pharmacotherapies that may be ineffective.

In March, a few of the nation’s researchers in neurocognitive disorders held a session at the American Association for Geriatric Psychiatry Annual Meeting in New Orleans to give an overview of the BPSD and a rundown of the most current evidence-based research for pharmacological interventions to treat such symptoms.

“BPSD are noncognitive symptoms and behaviors that are overwhelmingly common in patients with dementia,” said Aarti Gupta, M.D., a geriatric psychopharmacology research fellow at Yale School of Medicine. “There are several categories of BPSD, including depression, anxiety, agitation, and aggression… [and] psychotic symptoms, such as delusions, and sleep-wake disorders.” She explained that 65 percent of community-dwelling people with dementia display at least one behavioral disturbance symptom, whereas BPSD affects 90 percent of those residing in nursing homes.

During her presentation, Gupta highlighted research by George Grossberg, M.D., a professor of psychiatry and neurology at St. Louis University, which showed that symptoms of behavioral disturbances—such as social withdrawal, depression, and paranoia—were reported in patients with dementia up to 40 months prior to a diagnosis for the cognitive disorder.

“These results emphasize that a cognitive test and comprehensive exam should be in place when elderly people are presenting new psychiatric symptoms,” Gupta told Psychiatric News. “Though these are primary psychiatric symptoms, these symptoms may be caused by factors leading to onset of dementia, or they could be a result of an underlying neurological disorder or medical condition. It’s really important to test; there’s no harm in doing so.”

Session presenter Rajesh Tampi, M.D., M.S., chief of geriatric psychiatry at MetroHealth Medical Center of Case Western Reserve University, explained that available data indicate that there are many different therapies and medications that are beneficial in the treatment of BPSD, but clinicians need to be sure to choose a medication that is relevant to the symptoms being targeted.

“The data for using antidepressants show that such medicines are beneficial for treating symptoms of depression and anxiety in people with dementia,” Tampi told Psychiatric News. “Antipsychotic drugs are helpful for treating delusion and hallucinations, as well as for the treatment of aggression.”

He added that data for using anticonvulsive medication to control aggression are inconclusive and that benzodiazepines should never be used to treat BPSD due to recent findings showing the medications’ association with increased risk for cognitive decline in elderly patients (Psychiatric News, April 17).

Tampi said that though mood stabilizers are commonly prescribed to treat BPSD, there are no data showing benefits of this drug class in populations with dementia. “Because there is no approved pharmacological therapy for behavioral and psychological symptoms of dementia, it is very important for us to pay close attention [to] clinical trials on medications that are often prescribed to our patients,” he told attendees. “We cannot afford to waste time.”

While several clinical trials are ongoing for drug candidates intended to treat BPSD, Tampi said that physicians must put more emphasis on the use of nonpharmacological management, which is suggested as the first line of therapy of BPSD outlined by the Centers for Medicare and Medicaid Services, here. ■