Raj K. Kalapatapu, MD, is a Fellow in Geriatric Psychiatry, Mount Sinai School of Medicine, New York City.
Judith A. Neugroschl, MD, is Assistant Professor, Department of Psychiatry, Mount Sinai School of Medicine.
Disclosure: The authors state that they have nothing to disclose.
ABSTRACTThe neuropsychiatric symptoms of dementia can lead to a decreased quality of life, rapid cognitive decline, early patient
institutionalization, tremendous caregiver burden, and increased cost of care. A thorough assessment to evaluate and treat
any underlying causes of symptoms is essential. With the lack of an approved drug to treat the neuropsychiatric symptoms of
dementia, nonpharmacologic interventions take on added importance. Behavioral management, cognitive stimulation therapy, and
caregiver and health care staff education have shown the most promise to reduce symptom burden over the long term. The antipsychotic
drugs have been the traditional choice of medications to treat the neuropsychiatric symptoms of dementia, but safety problems
emerged with their use, leading to the issuance of label changes ("black box" warnings) by the Food and Drug Administration.
Aside from antipsychotic drugs, multiple classes of medications have been tried to treat such symptoms but long-term data
showing efficacy and safety are often lacking.
Kalapatapu RK, Neugroschl JA. Update on neuropsychiatric symptoms of dementia: Evaluation and management. Geriatrics. 2009;64(4):20-26.
Key words: dementia, update, evaluation, management
Drugs discussed: buspirone, carbamazepine, citalopram, chlordiazepoxide, diazepam, donepezil, diphenhydramine, gabapentin,
haloperidol, lithium carbonate, lamotrigine, medroxyprogesterone, memantine, oxazepam, risperidone, trazodone, valproate
Figure 1: Neuropsychiatric symptoms of dementia
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The neuropsychiatric symptoms of dementia are perhaps the most distressing and difficult-to-treat features of the disease
(Figure 1). This review addresses the process of evaluating neuropsychiatric symptoms to help guide treatment, the evidence
for and specific examples of nonpharmacologic interventions, and the various classes of pharmacologic interventions (excluding
antipsychotics) that may be helpful in the treatment of neuropsychiatric symptoms. A subsequent article will review the use
of antipsychotic medications to treat the neuropsychiatric symptoms of dementia.
Neuropsychiatric symptoms of dementia
Although cognitive and functional decline are the cardinal features of dementia, the associated behavioral and psychiatric
symptoms often prove most stressful and debilitating for patients and caregivers. Indeed, 60% of community-dwelling patients
eventually develop neuropsychiatric symptoms, and more than 80% of patients with dementia in nursing homes suffer from these
symptoms.1
Figure 2: Problems associated with neuropsychiatric symptoms of dementia
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In addition to being common, these symptoms carry additional risks, such as impaired quality of life, an additional cost of
care, rapid cognitive decline, and tremendous caregiver burden (Figure 2).1-3 These symptoms can shorten the time to nursing home placement by as much as 2 years.4 Some studies even report a connection between neuropsychiatric symptoms and increased mortality, whereas other studies
have not found such an association.1Significant caregiver burden, in particular, carries with it repercussions for patients and families, as caregiver stress
is associated with early patient institutionalization.1 Caregiver stress increases the risk of substandard care, neglect, or abuse of patients, and indicates that caregivers themselves
are in need of evaluation and psychosocial support.3 Signs of caregiver stress include depression, anxiety, increased anger, social withdrawal, sleeplessness, irritability,
poor concentration, and lower levels of subjective well-being, physical health, and self-efficacy.3,5
As common and debilitating as neuropsychiatric symptoms are, clinicians have few ways to treat them adequately, as there
currently are no treatments approved by the US Food and Drug Administration (FDA).2 Moreover, recent data have resulted in the FDA issuing "black box" warnings for several classes of medications, adding difficulty
to choosing a medication to treat neuropsychiatric symptoms.1-3 Once medical and environmental etiologies of these behaviors are ruled out, a clear strategy for management of these symptoms
is lacking, although many somatic and behavioral interventions have been tried and studied.
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