Management of the behavioral symptoms associated with dementia

Dementia-related behavioral symptoms present a difficult management problem for caregivers and health care providers. The first step in the treatment of behavioral symptoms in the elderly should involve nonpharmacologic measures. This should include the exclusion of medication-induced dementia and delirium, which is an important consideration in the elderly owing to multiple medication use and alterations in pharmacokinetics and pharmacodynamics. Other measures involve relatively simple environmental changes. If these are unsuccessful, pharmacologic management is often tried. Numerous concerns surround the use of antipsychotics, which are the primary agents used to treat behavioral symptoms in demented elderly. The public is concerned about their inappropriate use as chemical restraints. Another concern involves the efficacy of these agents. Most well-designed studies demonstrate an overall modest effect from the antipsychotics that is often similar to that seen with placebo. There may be a small number of patients who respond markedly, whereas the majority do not receive great benefit. Unfortunately, all are exposed to the numerous side effects of these agents, including some irreversible movement disorders. If these agents are believed to be necessary, efforts should be made to use them in a manner that reduces the associated risks. A few other agents have been noted to successfully treat the problem behaviors associated with dementia, but most have been in the form of case reports. It appears that the optimal treatment of these problems relies on future research in the area of nonantipsychotic modalities that will be efficacious and have a rather benign side effect profile.