Cases of dementia in the elderly population continue to rise and pose a difficulty of treatment for both caregivers and physicians. Symptoms of dementia present as delusions, delusional misidentifications, hallucinations, agitation, wandering and other psychotic behaviors (approx. 15-75% of reported cases). First course of action typically includes nonpharmacologic treatments such as removing physical and emotional stressors and establishing daily routines. However, in some cases physicians elect to prescribe off-label antipsychotics: Aripiprazole, olanzapine, quetiapine, and risperidone are examples of the most common ones.

Results

Nonpharmacologic management Is considered the first treatment basis against cases of behavioral and psychological symptoms of dementia. These treatments should cover against physical discomforts such as thirst, hunger, pain, sleep deprivation, depression, loneliness, boredom, and overstimulation. Routines are needed to correct behaviors and safety concerns. Along with physical, cognitive interventions are needed. This is often seen in the form of regularly scheduled stimulating activities, such as engaging with other people and remembering past experiences. Sensory stimulation is often needed as well, in forms of aromatherapy, light therapy, and music therapy.

Antipsychotics are often last resort options to treat severe behavioral and psychological symptoms of dementia. There is low-quality evidence in the benefit of these antipsychotics and more evidence of harm, as shown as the use of antipsychotics are not FDA approved. The usage is indicated in patients only if behaviors pose a risk of harm to oneself or others. Through three meta-analyses of atypical antipsychotics, results were as followed: aripiprazole (brand name: abilify) when used in lower dosages of 2-10mg per day resulted in small average reductions of behavioral and psychological symptoms of dementia. While Olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal) showed inconsistent results in treatment of dementia symptoms, with olanzapine and quetiapine having the least impact.

Discussion

What attracted me to this article was the conversation it invited on the course of treatment in patients with Dementia. In most situations, we tend to correlate diagnosis with treatment of prescription drugs. If your kid gets sick, give them antibiotics. If you feel depressed, you receive antidepressants. However, in cases of neurological disorders it begins to blur the lines of treatment options. How do you communicate with the brain when the brain isn’t communicating within itself? A better way to picture this is sending mail to a house and hoping they open it and respond; you can’t control anything other than the sending process. Because of this, we need to think outside the box treatment options. Prescription drugs are not always the solution.

Some questions to think about regarding this post include:

• Should aripiprazole be used in early stages of dementia if it has shown effectiveness?
• What should science focus on developing: more effective antipsychotics or better intervention treatments?
• How would you go about treatment options if a loved one showed symptoms of dementia?

Reese TR, Thiel DJ, Cocker KE. Behavioral Disorders in Dementia: Appropriate Nondrug Interventions and Antipsychotic Use. Am Fam Physician. 2016 Aug 15;94(4):276-82. PMID: 27548592.