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Behavioral Symptoms
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• Managing behavioral symptoms
• Evaluation of Alzheimer's behavioral symptoms
• Treatment options
• Helpful hints when a person becomes agitated
• Medications to treat behavioral symptoms

Managing behavioral symptoms

Alzheimer’s disease is best known as a memory disorder. However, behavioral and psychiatric symptoms may also occur. Many, but not all, individuals with Alzheimer’s will develop them.

  • Early in the disease, people may experience irritability, anxiety or depression.

  • Later in the disease, people may develop:

    • Agitation (verbal or physical outbursts, general emotional distress, restlessness, pacing, shredding paper or tissues)

    • Sleep disturbances

    • Delusions

    • Hallucinations

Many people with Alzheimer’s and their families find behavioral symptoms the most challenging and distressing aspects of the disease. These symptoms are often a determining factor in residential care placement. They also have an enormous impact on quality of life for individuals in long-term care.

Evaluation of Alzheimer's behavioral symptoms

The chief cause of behavioral symptoms is the progressive loss of brain cells. Other issues, including various medical conditions and environmental influences, may also play contributing roles. Some of these secondary issues may be correctible. Anyone experiencing behavioral symptoms should receive a thorough medical evaluation. With proper intervention, patients’ symptoms can often be reduced or stabilized.

Contributing medical conditions may include:

  • Infections of the ear, sinuses or urinary or respiratory tracts

  • Constipation

  • Uncorrected problems with hearing or vision

  • Pain

  • Medication side effects or drug interactions

Contributing environmental influences may include:

  • Change in caregiving arrangements

  • Admission to a hospital to treat a coexisting condition

  • Travel

  • Presence of houseguests

  • Being asked to bathe or change clothes

  • Moving to a new home

  • Entering long-term care

  • Difficulty with expressing needs and wishes

  • Fear and fatigue from trying to make sense out of an increasingly confusing world

Treatment options

There are two major types of treatment for behavioral symptoms:

  • Nondrug strategies

  • Prescription medications

Nondrug strategies should always be tried first. General principles of success in nondrug intervention include:

  • Creating a calm environment

  • Attempting to identify the cause of the behavior and change the environment accordingly

  • Appreciating that the person does not intend to be mean or difficult

  • Checking for hunger, thirst, full bladder and constipation

  • Monitoring comfort factors, including room temperature, glare and excessive background noise from television or other sources

  • Providing an opportunity for exercise

  • Redirecting the person’s attention rather than arguing or being confrontational

  • Simplifying the environment, tasks and routines

  • Allowing adequate rest between stimulating events

  • Alleviating confusion with labels to cue or remind the person

  • Increasing safety by equipping doors and gates with locks, and removing guns and other weapons

  • Reducing risk of fires by installing extra smoke alarms and controlling access to the stove

  • Using lighting to reduce nighttime confusion and restlessness

Helpful hints when a person becomes agitated

Things to do:

  • Use calm, positive statements

  • "Back off" and ask permission

  • Reassure

  • Slow down

  • Add light

  • Offer guided choices between two options

  • Focus on pleasant events

  • Offer simple exercise options

  • Try to limit stimulation

Things to say:

  • May I help you?

  • Do you have time to help me?

  • You are safe here.

  • Everything is under control.

  • I apologize.

  • I’m sorry that you are upset.

  • I know it’s hard.

  • I will stay with you until you feel better.

Do not:

  • Raise your voice

  • Make sudden movements

  • Show alarm or offense

  • Corner, crowd or restrain

  • Demand, force or confront

  • Rush or criticize

  • Ignore or argue

  • Shame or condescend

Medications to treat behavioral symptoms

If nondrug 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 nondrug approaches.

  • Medications should target specific symptoms so their effect can be monitored.

  • In general, it is best to start with a low dose of a single drug.

  • Effective treatment of one symptom may help relieve other symptoms. For example, some antidepressants may also help people sleep better.

Choice of medication is based on many factors. These include the underlying cause of dementia and an individual’s symptoms, living situation and coexisting health conditions.

When considering medications, it is important to understand that no drugs are specifically approved by the U.S. Food and Drug Administration to treat behavioral and psychiatric dementia symptoms. Many of the examples discussed here represent "off label" use, a 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 include:

  • Citalopram (Celexa)

  • Fluoxetine (Prozac)

  • Paroxetine (Paxil)

  • Sertraline (Zoloft)

  • Trazodone (Desyrel)

Antipsychotic medications for hallucinations, delusions, aggression, agitation and uncooperativeness include:

  • Aripiprazole (Abilify)

  • Olanzapine (Zyprexa)

  • Quetiapine (Seroquel)

  • Risperidone (Risperdal)

  • Ziprasidone (Geodon)

  • Haloperidol (Haldol)

The decision to use an antipsychotic drug needs to be considered with extreme caution. Recent studies have shown that these drugs are associated with an increased risk of stroke and death in older adults with dementia. The FDA has labeled the drugs with a "black box" warning about this risk and a reminder that they are not approved to treat dementia symptoms.

To maximize the chances of effectiveness:

  • Tailor the choice of drug, how long to use it and when to discontinue it to the individual’s symptoms and circumstances.

  • Consider the underlying cause of a person’s dementia. For example, it is generally inadvisable for patients who have dementia with Lewy bodies (DLB) to take antipsychotic drugs.

Anti-anxiety drugs for anxiety, restlessness, verbally disruptive behavior and resistance to treatment include the following.

  • For short-term treatment of acute symptoms:


    • Lorazepam (Ativan)
    • Oxazepam (Serax)

  • For long-term treatment:


    • Antidepressants may be useful

View Alzheimer's Association Statement Regarding the Treatment of Behavioral and Psychiatric Symptoms of Alzheimer's Disease

Medications for sleep problems: Some medications are approved specifically by the FDA as "sleeping pills" or sedative hypnotics. Most physicians tend to avoid prescribing "sleeping pills" for older adults with dementia. For such individuals, these drugs may cause incontinence, falls, increased agitation and other serious side effects.

Trazodone (Desyrel), an antidepressant that tends to make people sleepy, is one widely used alternative. Anti-anxiety medications are also used.

In addition, physicians 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 has strong anticholinergic effects, further suppressing the activity of one of the main cell-to-cell communication systems affected by Alzheimer’s disease.

Examples of over-the-counter sleep aids that should be avoided include:

  • Compoz

  • Nytol

  • Sominex

  • Unisom

  • Many "nighttime" or "PM" versions of popular pain relievers and cold and sinus remedies.

View a full list of anticholinergic medications.

Refer your patients’ caregivers to our Stages and Behaviors section in our Alzheimer’s and Dementia Caregiver Center.


 

Alzheimer's Association

Our vision is a world without Alzheimer's
Formed in 1980, the Alzheimer's Association is the world's leading voluntary health organization in Alzheimer's care, support and research.