When Alzheimer’s disrupts memory, language, thinking and reasoning, these effects are referred to as “cognitive symptoms” of the disease. The term “behavioral and psychiatric symptoms” describes a large group of additional symptoms that occur to at least some degree in many, but by no means all, individuals with Alzheimer’s.
In early stages of the disease, people may experience personality changes such as irritability, anxiety or depression. In later stages, other symptoms may occur, including sleep disturbances; agitation (physical or verbal outbursts, general emotional distress, restlessness, pacing, shredding paper or tissues, yelling); delusions (firmly held belief in things that are not real); or hallucinations (seeing, hearing or feeling things that are not there).
Many individuals with Alzheimer’s and their families find behavioral and psychiatric symptoms to be the most challenging and distressing effects of the disease. These symptoms are often a determining factor in a family’s decision to place a loved one in residential care. They also often have an enormous impact on care and quality of life for individuals living in long-term care facilities.
A person exhibiting behavioral and psychiatric symptoms should receive a thorough medical evaluation, especially when symptoms come on suddenly. Treatment depends on a careful diagnosis, determination of the possible causes, and the types of agitated behavior the person is experiencing. With proper treatment and intervention, significant reduction or stabilization of the symptoms can often be achieved.
Symptoms often reflect an underlying infection or medical illness. The pain or discomfort caused by pneumonia or a urinary tract infection can result in agitation. An untreated ear or sinus infection can cause dizziness and pain that affect behaviors. Uncorrected problems with hearing or vision may also have an impact. Side effects of prescription medication are another common contributing factor to behavioral symptoms. Side effects are especially likely to occur when individuals are taking multiple medications for several health conditions, creating a potential for drug interactions.
There are two distinct types of treatments for behavioral and psychiatric symptoms: non-drug strategies and prescription medications. Non-drug interventions should be tried first. In general, steps to managing symptoms include (1) identifying the behavior, (2) understanding its cause and (3) adapting the caregiving environment to remedy the situation.
Correctly identifying what has triggered symptoms can often help in selecting the best approach. Often the trigger is some sort of change in the person’s environment:
- change in caregiver
- change in living arrangements
- presence of houseguests
- being asked to change clothing
A key principle of intervention is redirecting the person's attention, rather than arguing, disagreeing or being confrontational. Additional strategies include the following:
- simplify the environment
- simplify tasks and routines
- allow adequate rest between stimulating events
- use labels to cue or remind the person
- equip doors and gates with safety locks
- remove guns
- reduce risk of fires with extra smoke alarms and control access to the stove
- use lighting to reduce confusion and restlessness at night
If non-drug approaches fail after they have been applied consistently, introducing medications may be appropriate when individuals have severe symptoms or have the potential to harm themselves or others. Medications can be effective in some situations, but they must be used carefully and are most effective when combined with non-drug approaches.
Medications should target specific symptoms so their effects can be monitored. In general, it is best to start with a low dose of a single drug. Effective treatment of one core symptom may sometimes help relieve other symptoms. For example, some antidepressants may also help people sleep better. Individuals taking medications for behavioral symptoms must be closely monitored. People with dementia are susceptible to serious side effects, including stroke and an increased risk of death from antipsychotic medications.
Sometimes medications can cause an increase in the symptom being treated. Without careful evaluation, some medical providers will increase rather than decrease the dose, putting the person at greater risk. Risk and potential benefits of a drug should be carefully analyzed for any individual.
When considering use of medications, it is important to understand that no drugs are specifically approved by the U.S. Food and Drug Administration (FDA) to treat behavioral and psychiatric dementia symptoms. Some of the examples discussed here represent “off label” use, a medical practice in which a physician may prescribe a drug for a different purpose than the ones for which it is approved.
Antidepressant medications for low mood and irritability
- citalopram (Celexa®)
- fluoxetine (Prozac®)
- paroxetine (Paxil®)
- sertraline (Zoloft®)
- trazodone (Desyrel®)
Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance
- lorazepam (Ativan®)
- oxazepam (Serax®)
Antipsychotic medications for hallucinations, delusions, aggression, hostility and uncooperativeness
- newer "atypical" agents such as aripiprazole (Abilify®); olanzapine (Zyprexa®); quetiapine (Seroquel®); risperidone (Risperdal®); and ziprasidone (Geoden®)
- older first-generation drugs such as haloperidol (Haldol®)
The decision to use an antipsychotic drug needs to be considered with extreme caution. A recent analysis shows that atypical antipsychotics are associated with an increased risk of stroke and death in older adults with dementia. The FDA has asked manufacturers to include a “black box” warning about the risks and a reminder that they are not approved to treat dementia symptoms. The warning states: “Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo.”
The analysis states that while risperidone and olanzapine are useful in reducing aggression and risperidone reduces psychosis, both drugs are associated with severe side effects. Despite some efficacy, these drugs should not be used routinely with dementia patients, unless the person is in severe distress or there is a marked risk of harm.
To maximize the chances of effectiveness, the choice of a particular drug, how long it should be used and when it should be discontinued all need to be carefully tailored to an individual's symptoms and circumstances. The underlying cause of a person's dementia may also influence the selection of a drug. For example, it is generally considered inadvisable for individuals with dementia with Lewy bodies (DLB) to take antipsychotic drugs.
Many experts recommend that use of drugs to treat agitation, aggression, hallucinations and delusions in persons with dementia be managed by a physician with experience and interest in this area.
Some medications are approved specifically by the U.S. Food and Drug Administration (FDA) as “sleeping pills.” Most physicians tend to avoid prescribing “sleeping pills” for older adults with dementia, since in this group these drugs may have serious side effects, including incontinence, problems with balance, falls or increased agitation.
- one widely used alternative is the antidepressant trazodone (Desyrel®), which tends to make people sleepy
- anti-anxiety medications are also sometimes used
Physicians also recommend that individuals with dementia avoid over-the-counter sleep remedies. The active ingredient in many of these preparations is diphenhydramine (Benadryl®), an antihistamine that tends to make people feel drowsy. Diphenhydramine further suppresses the activity of one of the main brain cell messenger chemicals whose activity is reduced by Alzheimer’s disease.
Examples of over-the-counter sleep aids containing diphenhydramine that should be avoided include:
- Compoz®, Nytol®, Sominex® and Unisom®
- diphenhydramine is also an ingredient in many “nighttime” or “PM” versions of popular pain relievers and cold and sinus remedies
Helpful hints during an episode of agitation
Do: back off and ask permission, use calm positive statements, reassure, slow down, use visual or verbal cues, add light, offer guided choices between two options, focus on pleasant events, offer simple exercise options, or limit stimulation.
Do not: raise voice, take offense, corner, crowd, restrain, rush, criticize, ignore, confront, argue, reason, shame, demand, condescend, force, explain, teach, show alarm, or make sudden movements out of the person’s view.
Say: May I help you? Do you have time to help me? You’re safe here. Everything is under control. I apologize. I’m sorry that you are upset. I know it’s hard. I will stay until you feel better.
Create a calm environment: remove stressors, triggers or danger; move person to a safer or quieter place; change expectations; offer security object, rest or privacy; limit caffeine use; provide opportunity for exercise; develop soothing rituals; and use gentle reminders.
Avoid environmental triggers: noise, glare, insecure space, and too much background distraction, including television.
Monitor personal comfort: check for pain, hunger, thirst, constipation, full bladder, fatigue, infections, and skin irritation; ensure a comfortable temperature; be sensitive to fears, misperceived threats, and frustration with expressing what is wanted.
This content was developed by the Alzheimer’s Association Medical and Scientific Advisory Council.