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Evaluating the Behavioral and Psychological Symptoms of Dementia
Quick Start: Evaluating the Behavioral and Psychological Symptoms of Dementia
| The behavioral and psychological symptoms of dementia |
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| Benefits of treatment |
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| Evaluating behavioral and psychological symptoms of dementia |
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| Formulating a treatment plan |
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Patient EB is an 84-year-old woman who is living with her two nieces. She moved to the United States at age 22, never married, and worked in the fashion industry in New York, retiring at age 65 years. She has memory problems (denies having conversations, repeats questions), problems with executive functioning (difficulty managing finances and inappropriately gave away money), and visuospatial functioning (becomes lost walking in her neighborhood). She denies any cognitive deficits and does not understand why she needs to live with her nieces. She is agitated, expressed by constantly berating her nieces, denying her problems, and attempting to wander in the neighborhood. Her nieces are extremely frustrated in attempting to care for her. We diagnosed her with Alzheimer’s disease and then had a discussion with the patient and her nieces regarding treatments.
Recall the case of EB from Chapter 18 . Until now we have been discussing treatments for the cognitive aspects of Alzheimer’s disease. But, as case EB demonstrates, changes in cognition and the problems that ensue because of it are only part of the problem in Alzheimer’s disease (as well as other dementing illnesses). There are accompanying behavioral symptoms as well, which have significant management consequences. To wit, we have learned from our families that, in many respects, the stresses and demands of caring for a patient with behavioral problems is often the primary challenge. As one caregiver succinctly characterized the challenges in dealing with the behavioral and psychological symptoms of dementia:
When my wife would forget to buy my favorite foods at the supermarket I was upset, but when she started screaming at me to get out of our bed because she did not sleep with strangers, I knew the disease had reached a whole different level.
There has been considerable effort in recent years to develop both behavioral and pharmacological treatments for what has become known as “the behavioral and psychological signs and symptoms of dementia” ( ). Clinicians now realize that caring for these symptoms is a central part of caring for the patient with Alzheimer’s disease and other dementias ( Table 24.1 ).
Table 24.1
Dementias and Selected Neurodegenerative Disorders That Commonly Manifest Behavioral and Psychological Symptoms
From Cummings, J. L. (2003). The neuropsychiatry of Alzheimer’s disease and related dementias (Ch. 2, p. 32). London: Martin Dunitz Ltd.
| Behavioral/Psychological Symptom | Dementia |
|---|---|
| Apathy |
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| Depression |
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| Hallucinations |
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| Delusions |
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| Agitation/aggression |
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| Disinhibition |
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What Constitutes Behavioral and Psychological Symptoms of Dementia?
There are many symptoms that can be classified in the category of behavioral and psychological symptoms of dementia, and considerable effort has been devoted to arriving at a classification scheme. One such scheme that was presented at the first consensus conference for these symptoms in 1996 ( ) suggests that two general categories of symptoms can be evaluated:
Symptoms usually assessed on the basis of interviews with patients and relatives. These symptoms include anxiety, depressive mood, hallucinations, and delusions.
Symptoms usually identified on the basis of observation of patient behavior including aggression, screaming, restlessness, agitation, wandering, culturally inappropriate behaviors, sexual disinhibition, hoarding, cursing, and shadowing.
The Benefits of Treating Behavioral and Psychological Symptoms of Dementia
Treating these symptoms has many potential benefits for patients and caregivers. Both patients and caregivers report experiencing considerable distress when patients display these symptoms ( ). As noted above, it has been our experience that little is more distressing to caregivers than these symptoms. Treating these symptoms can help reduce stress in the family setting. By reducing stress, treating behavioral and psychological symptoms of dementia can improve the quality of life for patients and caregivers and may reduce the risk of institutionalization. Additionally, treating these symptoms may improve cognition and functional ability and decrease the patient’s dependence on the caregiver.
Measuring Behavioral and Psychological Symptoms of Dementia
There are now a variety of methods of measuring behavioral and psychological symptoms of dementia, ranging from informant interviews to validated scales. Some scales focus on a single symptom (e.g., depression) whereas others rate multiple symptoms. The Geriatric Depression Scale ( ) and the Cornell Scale for Depression ( ) are commonly used to rate depression, and the Cohen-Mansfield Agitation Inventory is widely used to measure agitation ( ). The BEHAVE-AD ( ) is an example of a multisymptom rating scale, as is the widely used Neuropsychiatric Inventory ( ).
The Neuropsychiatric Inventory is designed to provide a multidimensional profile of the behavioral and psychological symptoms that accompany dementia ( ). It is predicated on three assumptions that have been supported by research findings:
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As cognition worsens, behavioral changes become more likely.
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Multiple, simultaneous symptoms are the rule in patients with Alzheimer’s disease ( Fig. 24.1 ). For example, patients commonly exhibit agitation, psychosis, and depression.
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Once symptoms occur, they tend to persist.
The behavioral and psychological symptoms that are included in the Neuropsychiatric Inventory provide both a summary of what clinicians might expect to encounter and a framework for measuring/evaluating these symptoms ( Table 24.2 ).
Table 24.2
Neuropsychiatric Screening Questions
| Behavioral/Psychological Symptom | Probe From the Neuropsychiatric Inventory |
|---|---|
| Delusions | Does the patient have beliefs that you know are not true (for example, insisting that people are trying to harm him/her or steal from him/her)? Has he/she said that family members are not who they say they are or that the house is not their home? I’m not asking about mere suspiciousness; I am interested if the patient is convinced that these things are happening to him/her. |
| Hallucinations | Does the patient have hallucinations, such as seeing false visions or hearing imaginary voices? Does he/she seem to see, hear, or experience things that are not present? By this question, we do not mean just mistaken beliefs such as stating that someone who has died is still alive; rather, we are asking if the patient actually has abnormal experiences of sounds or visions. |
| Agitation/aggression | Does the patient have periods when he/she refuses to cooperate or won’t let people help him/her? Is he/she hard to handle? |
| Depression | Does the patient seem sad or depressed? Does he/she say that he/she feels sad or depressed? |
| Anxiety | Is the patient very nervous, worried, or frightened for no apparent reason? Does he/she seem very tense or fidgety? Is the patient afraid to be apart from you? |
| Elation/euphoria | Does the patient seem too cheerful or too happy for no reason? I don’t mean the normal happiness that comes from seeing friends, receiving presents, or spending time with family members. I am asking if the patient has a persistent and abnormally good mood or finds humor where others do not. |
| Apathy/indifference | Has the patient lost interest in the world around him/her? Has he/she lost interest in doing things or does he/she lack motivation for starting new activities? Is he/she more difficult to engage in conversation or in doing chores? Is the patient apathetic or indifferent? |
| Disinhibition | Does the patient seem to act impulsively without thinking? Does he/she do or say things that are not usually done or said in public? Does he/she do things that are embarrassing to you or others? |
| Irritability | Does the patient get irritated and easily disturbed? Are his/her moods very changeable? Is he/she abnormally impatient? We do not mean frustration over memory loss or inability to perform usual tasks; we are interested to know if the patient has abnormal irritability, impatience, or rapid emotional changes different from his/her usual self. |
| Aberrant motor behavior | Does the patient pace, do things over and over such as opening closets or drawers, or repeatedly pick at things or wind string or threads? |
| Sleep and night-time behavior disorders | Does the patient have difficulty sleeping? (Do not count as present if the patient simply gets up once or twice per night only to go to the bathroom and falls back asleep immediately.) Is he/she up at night? Does he/she wander at night, get dressed in the middle of the night, or disturb your sleep? |
| Appetite and eating disorders | Has he/she had any change in appetite, weight, or eating habits? (Count as N/A if the patient is incapacitated or has to be fed.) Has there been any change in the type of food he/she prefers? |
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