Many patients with Alzheimer s disease

Transcription

1 NEUROPSYCHIATRIC SYMPTOMS AND BEHAVIORAL PROBLEMS OF ALZHEIMER S DISEASE: A NURSE S PERSPECTIVE Carol Fedor, ND* ABSTRACT Patients with Alzheimer s disease (AD) exhibit, in addition to cognitive decline, neuropsychiatric and behavioral symptoms, the frequency and severity of which may increase as the disease progresses. These symptoms can have any number of causes beyond the neuronal degeneration that occurs in the AD brain. Many of the behavioral symptoms are responses to negative or overwhelming stimuli (eg, loud noises, commotion, pain or discomfort, unfamiliar surroundings, and difficulty with daily routines). They manifest in patients with AD, in what appear to be severe or exaggerated forms because patients with AD are unable to communicate their discomfort and their coping skills are limited. Determining the cause of a behavioral symptom requires a methodical approach, beginning with defining the symptoms (ie, frequency, severity, antecedents, and consequences), along with medical and psychiatric evaluations, and an assessment of environmental influences. Many innovative and creative nonpharmacologic treatments have been tested with high levels of success. Nonpharmacologic treatments should be the first-line strategy, reserving pharmacotherapy for patients in which nonpharmacologic treatments have failed. Drug therapy is a doubleedged sword with potential benefits but also significant risks in the elderly, and it is important to remember that many medications treat only the *Clinical Research Manager, Center for Clinical Research, University Hospitals of Cleveland, Cleveland, Ohio. Address correspondence to: Carol Fedor, ND, Clinical Research Manager, Center for Clinical Research, University Hospitals of Cleveland, Euclid Avenue, Cleveland, OH carol.fedor@uhhs.com. symptoms, not the cause of an underlying problem. Effectively treating behavioral symptoms is often only accomplished through input from the entire healthcare team, which includes several disciplines, with the nurse in a position to provide the most personalized, targeted care that has the best chance of success. (Adv Stud Nurs. 2005;3(8): ) Many patients with Alzheimer s disease (AD) exhibit, in addition to cognitive decline, neuropsychiatric and behavioral symptoms, the frequency and severity of which can increase as the disease progresses (Figure 1). These symptoms can include anxiety, aggression, depression, verbal outbursts, impulsivity, hyperactivity, restlessness, wandering, withdrawal, and in more extreme cases delusions, hallucinations, and psychosis. Behavioral and neuropsychiatric symptoms require attention not only for the patient, but also the caregiver. They are a significant source of distress and detract from quality of life for caregivers; they are often a determining factor for families regarding institutionalization of the patient. 1,2 They also increase expensive levels of treatment (eg, hospitalization and institutionalization), and increase the risk of overmedication, restraints, and catastrophic reactions. 3-5 Neuropsychiatric and behavioral symptoms of AD can have any number of causes, beyond neuronal degeneration in the AD brain. Therefore, treatment should first focus on identifying possible medical or environmental causes. Pharmacologic treatment of Advanced Studies in Nursing 271

2 Figure 1. The Stages of Alzheimer s Disease Stage Symptoms Mild Moderate Severe Memory loss Language problems Mood and personality changes Diminished judgment Withdrawal from activities Need for memory aids daily Some help needed with IADLs neuropsychiatric and behavioral symptoms should be used with due diligence. Although medications may be temporarily effective, they do not address the source of the problem, which is often multifactorial in the elderly. As will be discussed later in this article, drugs are often ineffective and must be balanced with the significant side effects they incur, especially in cognitively impaired adults. ASSESSING BEHAVIORS Behavioral, personality changes Unable to learn or recall new info Long-term memory affected Wandering, paranoia, aggression, Require assistance with all IADLs Unstable gait Incontinence Motor disturbances Bedridden Dysphagia Mute Poor/no ADLs LTC placement common ADLs = activities of daily living; IADLs = instrumental activities of daily living; LTC = long-term care. Figure courtesy of Jeanne Jackson-Siegal, MD. Cohen-Mansfield suggests 3 theoretical models to explain distressed behaviors: the unmet needs model, a behavior/learning model, and an environmental vulnerability/reduced stress-threshold model. 6 In the unmet needs model, it is recognized that many nursing home residents who show inappropriate behaviors are actually responding to sensory deprivation, boredom, and loneliness, in addition to insufficient light levels, poor toileting procedures, inability to communicate, or undertreatment of pain. In the behavior/learning model, patients may learn that they can obtain the staff members attention by these behaviors. Therefore, the staff response reinforces the behavior. The environmental vulnerability/reduced stress-threshold model maintains that the progression of dementia renders the patient more sensitive to his or her environment, lowering the threshold at which stimuli affect behavior. 6 In fact, all of these models may explain the inappropriate behaviors often exhibited by patients with AD. Many of the behavioral symptoms are normal responses that cognitively intact people have to negative or overwhelming stimuli (eg, loud noises, commotion, pain or discomfort, unfamiliar surroundings, and difficulty with daily routines). They manifest in patients with AD, in what appear to be severe or exaggerated forms, because patients with AD are unable to communicate their discomfort and their coping skills are limited. Although a healthy adult who is feeling frustrated may go for a walk or listen to music, a patient with AD (especially in more severe stages) is limited in his/her ability to decompress or cope with the source of their frustration. A healthy adult in pain can modify their environment to decrease the source of pain or seek out a physician for treatment. The patient with AD, unable to recognize the source of their pain or communicate it, reacts with behavioral disturbances, such as anxiety, frustration, aggression, or withdrawal. Determining the cause of a behavioral symptom requires a methodical approach. The first step to assessing distressed behavior is to specifically define the symptoms, including frequency, severity, antecedents, and consequences. As part of the assessment, a medical and psychiatric evaluation should be completed as well as an assessment of environmental influences. Ideally, all 3 of these areas (ie, medical, psychiatric, and environmental) should be examined and, if needed, treated. In describing the patient s behavior, the term agitation is often used. This is a vague description that can be perceived differently by different observers and can imply a sense of blame (ie, the patient is being difficult ). Instead, the behaviors associated with agitation are better described as distressed, reminding us that the patient is reacting this way to an unpleasant stimulus. It is important to be specific, especially when documenting behavior and its treatment in nursing home facilities. Table 1 offers suggestions on using specific descriptors of distressed behaviors. 7,8 The behavioral symptoms and syndromes often overlap. For example, a single symptom, such as verbal abuse, can have several different psychiatric causes, in addition to possible environmental causes (Figure 2). As a result, a multifaceted approach to behavior assessment ensures that all possible causes of a single symptom are explored. Jackson-Siegal suggests a hierarchical approach to comprehensive behavioral assessment in patients with AD, comprised of 8 major components (Table 2) Vol. 3, No. 8 October 2005

3 This type of methodical approach is useful to clarify the cause(s) of the behavior(s). As will be discussed later in this article, environment is considered first because minor environmental changes can very often have a considerable impact on neuropsychiatric symptoms and behaviors. Delirium is defined as an acute disturbance of consciousness accompanied by a change in cognition or the development of perceptual disturbances. Delirium can be caused by a medical problem, such as pain, a urinary tract infection, or by medications or medication withdrawal. Delirium in AD is often transient and will most likely resolve, but the clinician must be prepared to identify it, seek effective treatment, and act quickly to avoid further problems. The symptoms of delirium can be accompanied by other psychiatric disturbances, such as depression, hallucinations, and delusions. Other symptoms of delirium can include tremor, incoherence, disorientation, and day/night reversal. 10 Behavioral symptoms in AD may be the result of underlying medical problems, most commonly gastroesophageal reflux disease, osteoarthritis, angina, constipation, hearing or vision impairment, sleep deprivation, dental problems, infection, or medication side effects. For example, a patient who is distressed at mealtime may in fact be responding to reflux or ulcer pain. Psychosis, broadly defined as a gross impairment in reality testing, can be a com- Table 1. Descriptors of Symptoms of Distress mon symptom in AD. Importantly, psychosis is a symptom, not a final diagnosis. Psychotic symptoms Physical* Verbal* Passive may be driven by a chronic psychotic mental disorder, or the dementia process itself. Memory impairment from dementia is easily mistaken for psychosis. For Hitting Threats Silence example, statements such as This is not my house, I Pacing Accusations Poor oral intake have to go to work, You aren t my wife; you re an Kicking Name-calling Withdrawal imposter, or I know you ve been cheating on me Biting Obscenities Dead weight may not be delusions but rather a distorted response to Pushing Complaining Listless impaired memory. Depression and anxiety are very Spitting Attention-seeking Hand wringing often comorbid with AD, and the symptoms can result Scratching Screaming Blank stare from any of several different causes, which should affect treatment choice. For example, a patient s confusing and chaotic environment can cause anxiety. In When describing behaviors, it is best to be as specific as possible. The term agitation is not helpful in developing a working diagnosis or in monitoring treatment efficacy, and it does not evoke empathy for the patient s situation. Use of the general term distressed is more empathic and use of specific descriptors of distressed behavior encompasses possible etiologies from environmental, medical, or psychiatric domains when considering treatment options. *Data from Cohen-Mansfield. 7 Figure 2. The Symptoms and Syndromes of Data from Tariot et al. 8 Alzheimer s Disease Overlap Frontal Lobe Impairment Impulsivity Hyperactivity Agitation Figure courtesy of Jeanne Jackson-Siegal, MD. Table 2. Hierarchical Paradigm for Comprehensive Behavioral Assessment in Geriatrics 1. Environment/stressors 2. Dementia 3. Delirium 4. Medical problems 5. Psychotic disorder 6. Affective disorder 7. Anxiety disorder 8. Personality disorder Data from Jackson-Siegal. 9 Anxiety Disorder Restlessness Irritability Verbal Abuse Aggression Psychotic Disorder Worry Physical Sx Anxiety Physical Aggression Withdrawal Delusions Hallucinations Dysphoria Vegetative Sx Major Depression Advanced Studies in Nursing 273

4 this case, using relatively benign interventions (eg, increased structure, less stimulation, or increased one-toone time) is preferable compared to the use of a benzodiazepine to unnecessarily calm the patient. Benzodiazepines have several adverse effects, including increased risk of falls, and they would treat the symptom of anxiety, but the cause would not be addressed. Neuropsychiatric symptoms and distressed behaviors can result from physiological and/or psychological problems. A careful behavior assessment can direct the clinician to the most appropriate treatment form. NONPHARMACOLOGIC INTERVENTIONS Research has demonstrated the benefits of nonpharmacologic interventions for behavioral symptoms as well as the limitations of pharmacotherapy (discussed later in this article). A successful strategy for addressing behavioral symptoms is to focus on prevention because it is difficult to confront the patient in the moment of the disturbance, and this may only tend to escalate the behavioral disturbance. Nonpharmacologic strategies, including those studies reviewed by Cohen-Mansfield, have used myriad methods to address behavioral symptoms. 6 Although the studies used to assess these methods vary widely in design, the interventions are highly innovative and the results show a resounding benefit from nonpharmacologic approaches. Table 3 lists the nonpharmacologic strategies that have been tested, including tactile and auditory stimulation, exercise, and environmental manipulation. Exercise can take the form of regular walks outside, gardening, or any activity that requires movement, depending on the patient s ambulatory ability. 6,11 Massage therapy can involve stroking, rubbing, brushing, or kneading (usually the back), or hand massage or therapeutic touching. 6,12 Aromatherapy has also been studied, using relaxing scents, such as lavender oil. 6,13 Music therapy has received a great deal of attention. Classical music is traditionally considered to be relaxing, but Gerdner found an improved response to individualized music from the patient s collection or music from an earlier period of the patient s life. 14,15 Because long-term memory is retained for a period of time in AD, familiar music from an early period in life can be comforting. Another auditory technique is white noise CDs of nature sounds or the ocean. In fact, natural environments appear to be helpful, even if simulated. Some nursing facilities decorate the halls with nature pictures and play sounds of nature, which are soothing. Other environmental changes can include a low-stimulus environment, in which lights are dimmed, there is no television or radio, people speak in lowered voices and have less rushed movement, the environment is decorated with neutral colors, and activities and eating are done in small groups. 6 Conversely, bright light therapy early in the morning can help with sundowning (a state of increased agitation, activity, and negative behaviors that happen late in the day through the evening hours) or sleeping problems. In these patients, activities should be limited to morning or early afternoon. 6 Patients with AD often experience low levels of stress in the morning; stressors accumulate as the day proceeds until they exceed the threshold, usually by early afternoon. 16 McCurry et al provide the first evidence that patients with AD who experience sleep problems benefit from a comprehensive sleep education program with their caregivers, which includes information on sleep hygiene, daily walking, and increased light exposure (using a light box). 17 Treatment gains were maintained at 6 months, with reductions in the number and duration of night awakenings. 17 Social contact is important, especially for patients who are feeling isolated. Increased one-to-one time is desirable. If the caregiver is unable to do this, some studies have used simulated presence, in which the caregiver videotapes or audiotapes him/herself and the Table 3. Possible Nonpharmacologic Interventions Exercise Massage therapy (hand and stroking) Aromatherapy Music therapy (sing along, preferred music, and classical music) White noise/nature sounds Simulated presence Natural environment (nature sounds and pictures of nature) Low-stimulus environment (no TV/radio, lowered lights, lowered voices, and less rushed movement) Light therapy One-to-one Behavior reinforcement Recreational interventions (manipulative, nurturing, sorting, and sewing) Outdoor activities Pet therapy (dogs and robocat) 274 Vol. 3, No. 8 October 2005

5 tape is played during bathing or dinner to help calm the patient. 6 One study recorded a family member as a one-sided phone conversation, leaving pauses for the patient to answer, making the patient feel as if they were in a conversation. 6 Another form of social interaction is pet therapy, with certified therapy dogs or companion animals. 6 Libin and Cohen-Mansfield have also tested a robocat (a robotic cat as a pet) and plush toy pet with some success. 18 These treatments have the advantage of avoiding pet allergies and not requiring daily care. Social contact can also be obtained through recreational activities that address certain skills, such as manipulation (eg, knitting and bead maze), nurturing (playing with dolls), sorting (puzzles), tactile (fabric book), sewing (lacing cards), and sound/music (melody bells and singing along or tapping foot to music). 6 Almost all of these techniques can be combined with behavior reinforcement, such as verbally rewarding the patient for good behavior or providing a tangible reward with massage or food. However, studies of this technique have failed to yield strong results. 6 With a review of these techniques, there are several key points for effectively using nonpharmacologic interventions. Virtually all of these strategies can be used by caregivers of community-dwelling patients with AD, and the nurse can provide appropriate instruction on the choice and method of treatments. Many of these techniques do not require much time. Hand massage lasts just a few minutes. One-to-one time can be as little as 30 minutes per day. Music and simulated presence can be played during care activities or at mealtimes. Combinations of therapies should be tried, and the therapies should be individualized for each patient. 6 As an example, Gerdner found greater success with music therapy when the music was individualized to the patient s life experience and preference compared to standard classical music. 14 Also, the type of behavior can provide some indication as to the most appropriate treatment. Patients who are restless and wandering would benefit from increased exercise or regular walks outdoors to relieve the feeling of being trapped or confined. Simulated presence is useful for those seeking attention or feeling ignored/lonely, or those patients who are hallucinating. 6 In working with the family to decide on nonpharmacologic treatments, a diary describing circumstances surrounding behavioral outbursts, such as who was present, the time of day, the location, and any precipitating factors, is extremely useful. It should include details, such as the type of behavior, whether the patient was hungry, what else was going on in the environment at that time, what was occurring before the behavior, and whether the patient needed to go to the bathroom. This type of diary can provide a wealth of information from which the nurse can design a treatment plan for the patient. It also involves the family in the patient s care. There are other environmental changes that can have a big impact on quality of life for the patient and family. Patients who get lost in their house or in a nursing facility will not benefit from seeing their name on a door. Rather, visual reminders such as photos or a memory box (with a glass case, filled with reminders from the past) can help to orient the patient in their surroundings. Similarly, if the patient is unable to get to the bathroom on time, they may not have incontinence. Rather, the patient may not recognize the bathroom door, and leaving the door open removes that obstacle. Conversely, laying dark tape on the floor or placing a grid in front of an exit door can prevent wandering, as patients sometimes hesitate to cross a threshold. 6 Cohen-Mansfield describes principles for nonpharmacologic interventions, which include the following: medical and nursing care that effectively address limitations in functioning (ie, pain, sensory limitations, and sleep problems) and in autonomy (eg, physical restraints); provision of social contact; provision of meaningful stimuli or activity; staff training to improve care; reduction in stressful stimuli or increasing relaxation during care activities; and tailoring the intervention to the individual. 6 Individualized treatment is based on several factors, most notably the immediate symptoms. For example, as Cohen- Mansfield suggests, patients who experience hallucinations benefit more from a videotape of family members talking to them, whereas those patients who request attention would be better served with more one-on-one time. However, beyond the behavioral symptoms, other important factors include cognitive level, social history, personality, sensory deficits, mobility, and stage of AD. 6 PHARMACOLOGIC TREATMENTS The most commonly used psychotropic drugs for the neuropsychiatric and behavioral symptoms of AD Advanced Studies in Nursing 275

6 are antipsychotics, antidepressants, benzodiazepines, cholinesterase inhibitors, and mood stabilizers. The goal of pharmacotherapy with psychotropics in patients with dementia is to relieve the behavioral signs and symptoms of dementia after nonpharmacologic interventions fail without causing undue side effects or exacerbating underlying cognitive impairment. 19 Psychotropic medications are a double-edged sword. Not all patients behavior improves with their use, and their side effects can be significant, particularly in the elderly. Figure 3 shows the many quality indicator domains that are affected by psychotropic medications positively or negatively. For example, if depression is diagnosed and appropriately treated with well-tolerated antidepressants, an anxious and depressed person may also improve their weight, cognitive abilities, and ability to perform activities of daily living (ADLs). Conversely, the same patient may have a more negative outcome if they are misdiagnosed and the symptoms are treated with benzodiazepines, with increased risk of negative side effects, such as impaired gait stability, worsened cognition, and decreased ADL function. Furthermore, benzodiazepines can worsen depression. Therefore, when psychotropic medications are targeted to specific symptoms without consideration of all possible causes, even the seemingly most appropriate medication can have negative outcomes. ANTIPSYCHOTIC DRUGS Conventional antipsychotic drugs are not effective in all dementia patients. It has been estimated that 33% of patients show improvement of behavioral symptoms with conventional antipsychotic treatment, at the expense of significant side effects, such as akathisia (motor restlessness and inability to sit still), parkinsonism, tardive dyskinesia (rhythmical involuntary movements of the tongue, face, and mouth or jaw), sedation, peripheral and central anticholinergic effects (which can counteract the benefits of cholinesterase inhibitors for cognitive function), postural hypotension, and cardiac conduction defects. 20 Newer antipsychotic agents (termed atypical ) offer improved side-effect profiles, but their use in treating patients with dementia is not especially well documented. Tariot et al reviewed the data for risperidone, olanzapine, quetiapine, and aripiprazole in studies of patients with AD. 19 The overall conclusion was that atypical antipsychotic agents are effective treatment for agitation (ie, distressing symptoms) in dementia, with a less clear impact on psychosis. Tolerability among the different agents varies substantially and should be considered when developing a treatment plan. The most frequent adverse events were somnolence, falls, injury, and extrapyramidal disorder. Importantly, none of these drugs is currently approved for treatment of psychosis with dementia. A more recent review by Sink et al showed that only olanzapine and risperidone offer convincing evidence of efficacy, but that the product labeling warning of cerebrovascular events must be balanced against any possible benefit in symptoms. 21 The US Food and Drug Administration (FDA) issued a public health advisory in April 2005 concerning the use of atypical antipsychotic medications in elderly patients with behavioral disturbances, which stated that there is an increased mortality in elderly patients with dementia who are receiving atypical antipsychotic drugs. 22 The FDA will probably include older antipsychotic medications in a similar warning because limited data also suggest an increase. Head-to-head studies of antipsychotic agents for AD neuropsychiatric and behavioral symptoms are lacking. A study of quetiapine versus rivastigmine for agitation and cognitive decline in institutionalized patients with dementia (n = 93) showed that neither drug was effective in the treatment of agitation, and quetiapine was associated with significantly greater Figure 3. Psychoactive Medications Affect All QI Domains Quality of Life Psychotropic Drug Use Physical/ Functioning Nutrition/Eating Skin Care QI Domains Infection Control Accidents Clinical Management Cognitive Patterns Elimination/ Incontinence Will the effect be positive or negative? QI = quality indicators. Figure courtesy of Jeanne Jackson-Siegal, MD. Behavioral and Emotional Problems 276 Vol. 3, No. 8 October 2005

7 cognitive decline than rivastigmine. 23 The National Institute of Mental Health is conducting a randomized, parallel-group, double-blind study comparing treatment with olanzapine, quetiapine, risperidone, and placebo in patients with AD with delusions or hallucinations and/or clinically significant aggression or agitation the Clinical Antipsychotic Trials of Intervention Effectiveness. The study is designed to compare the acute efficacy and effectiveness of risperidone, olanzapine, and quetiapine in treatment algorithms over the course of 36 weeks in treating psychosis in outpatients with AD, and to assess their relative effectiveness in maintaining clinical improvement up to 36 weeks. 24,25 The hypothesis is that the efficacy of all 3 agents will be equivalent, but the effectiveness may vary based on side effects, adherence, patient/caregiver satisfaction, and health utilization. 19 The goal is to provide guidance to clinicians in choosing which drugs can and should be used for hallucinations, delusions, or agitation associated with AD. CHOOSING AN ANTIPSYCHOTIC DRUG The selected antipsychotic drug and dose is chosen based on several factors, including patientspecific information, laboratory values, comorbid symptoms and illnesses, and medication-specific data (Table 4). Therapeutic effect and results of monitoring also have an impact upon the dose prescribed and the duration of administration. Generally, advanced age and a dementing illness require relatively low doses compared to the doses required to treat a chronic psychotic disorder, such as schizophrenia, symptoms in younger persons, or for those patients with intact cognition. In nursing care facilities, the Omnibus Budget Reconciliation Act (OBRA) of 1987 states that any drug when used in excessive dose is considered an unnecessary drug unless documentation is provided to show why higher doses are necessary. The interpretive guidance accompanying the OBRA regulations requires that the resident s symptoms be quantitatively and objectively documented (eg, on flow sheets or behavior-monitoring logs). The need for interventions, such as antipsychotic drugs, must be demonstrated based on description of the duration and nature of symptoms, and potential causes of the resident s symptoms must also be considered. The symptoms or behaviors must be sufficiently problematic (ie, present a danger to the resident or others or be continuous or severe enough to cause the resident distress or impaired function) to warrant antipsychotic drug usage. Although a single antipsychotic agent is usually sufficient to control symptoms, there can be clinical situations in which a second antipsychotic agent is helpful. For example, a patient may not tolerate an efficacious dose of a single agent without experiencing unacceptable side effects. Because each antipsychotic agent has a unique side-effect profile but generally equal efficacy, APPROPRIATE USE OF ANTIPSYCHOTIC DRUGS IN PATIENTS WITH ALZHEIMER S DISEASE As the clinician works through the hierarchy to determine (or eliminate) possible causes of behavioral symptoms, a working diagnosis is formed that is re-evaluated with each empirical therapy or change in patient status. Ideally, the cause would be identified before any medication is administered. Table 4. Factors That Affect Choice of Antipsychotic Agent for Patients with Alzheimer s Disease Resident-Specific Goal of treatment Compliance Age of the resident Length of treatment expected Other medications being administered Tolerance to the potential common side effects Specific condition being treated and related standards of practice Severity of symptoms Past history of exposure and tolerance/efficacy Laboratory Values Fasting glucose Fasting lipids HbA 1c Comorbid Symptoms Affective symptoms (eg, mania and depression) Weight (over or under) Psychomotor abnormalities Urinary urgency Urinary retention Edema Gait instability HbA 1c = glycosylated hemoglobin. Comorbid Illnesses Current tardive dyskinesia Parkinsonian symptoms caused by: Parkinson s disease Dementia with Lewy bodies Drug-induced parkinsonism Orthostatic hypotension Diabetes Hyperlipidemia Cognitive impairment Cardiovascular disease Conduction abnormalities Hypertension Tobacco dependence Other comorbid illnesses Osteoporosis Medication-Related Side-effect data specific to the condition being treated Side-effect data specific to use in elders Formulations available Flexibility of dosing Half-life Cost Manufacturer s recommendation Advanced Studies in Nursing 277

8 some patients may achieve better symptom control with reduced side effects by combining 2 different antipsychotic agents. In any situation, when a second agent is used, the reasons explaining the rationale for this approach must be included in the medical record. Many of the conditions for which antipsychotic agents are initially administered are temporary, such as delirium, dementia-related psychosis, and brief reactive psychosis. These conditions do not usually require long-term treatment, or can be controlled on doses that are safely lowered over time while maintaining good symptom control. When an antipsychotic agent is used in a nursing facility, documentation is required regarding the anticipated duration of time the drug will be administered. When psychotic symptoms are thought to be the result of the dementia process, a dose reduction is often successful after 4 to 6 months. This makes sense if we recognize that as the dementing illness continues to progress, symptoms would be expected to change over time. PRN (when needed) use of antipsychotic agents is sometimes necessary during dose tapering, ongoing treatment for catastrophic reactions, or acute changes in condition. All relevant documentation is still required in nursing facilities regarding indication, dosing, monitoring for effectiveness and side effects, and dose reduction, regardless of whether the drug is used continuously or on a PRN basis. In other healthcare environments or institutions in which patients with AD may reside (eg, hospitals and assisted living facilities), the policies for antipsychotic drug use may be specific to the institutions. Symptom-based treatment is common, but not ideal, for long-term antipsychotic usage. Note that the following symptoms alone would not be sufficient to justify the use of antipsychotic agents wandering, poor self-care, restlessness, impaired memory, anxiety, depression (without psychotic features), insomnia, unsociability, indifference to surroundings, fidgeting, and nervousness. Gurvich and Cunningham provide a useful overview of psychotropic drug use in nursing homes. 26 OTHER MEDICATIONS Mood stabilizers, anxiolytics, and antidepressants are also sometimes used for agitation in AD. The most frequently used mood stabilizers include haloperidol, valproate, and carbamazepine, although formal studies of these drugs for this treatment are limited A recent review of data by Sink et al found no effect with valproate and conflicting results with carbamazepine. 21 The most frequent adverse events with valproate use include thrombocytopenia and somnolence, in addition to weight gain, hair loss, tremor, and hepatotoxicity. 32 Cholinesterase inhibitors and memantine have shown a small but consistent benefit in addressing neuropsychiatric symptoms. 21,33-36 THE ROLE OF THE NURSE Nurses play a pivotal role in selecting, administering, and monitoring pharmacologic treatments. For nurses, the primary goal should be to identify the underlying causes of the patient s symptoms and not simply to subdue the symptoms. Although it may appear easier and faster to simply prescribe medications than to determine whether a patient s behavioral symptoms have a modifiable cause, nurses must be able to defer the use of antipsychotic drugs in situations in which they can address underlying problems to resolve symptoms and improve quality of life. Nurses should obtain a detailed history of the patient s current medications (to avoid drug-drug interactions). They should also understand that drug metabolism changes with age, due in part to declining renal function. Therefore, elderly patients often require lower doses of drugs than are normally used in younger adults. Nurses will need to educate the patient and family on the expected or possible side effects of medications and how to address them, in addition to the importance of compliance with the dosing regimen and the challenges they may face in following the treatment plan. Treating AD and its associated behavioral symptoms requires a multidisciplinary approach, including psychiatrists and other physicians, nursing staff, pharmacists, psychology, and other mental healthcare professionals. Cooperation among all involved helps to provide optimal, specific treatment plans because each offers insight into the many factors that may precipitate a particular behavior. For example, in a long-term care facility, the nursing staff has daily interaction with patients and can observe their behavior (and any changes in behavior). In primary care, the nurse has often formed a positive relationship with the patient and caregiver, thus more sensitive issues, such as neuropsychiatric and behavioral symptoms and the caregiver s frustration, can be more openly and thoroughly discussed. The nurse can work with the patient and caregiver to truly individualize a treatment plan that has the best chance of success. 278 Vol. 3, No. 8 October 2005

9 CONCLUSIONS Neuropsychiatric and behavioral symptoms of AD are often reactions to unpleasant stimuli. Patients with AD are unable to vocalize their discomforts or concerns, or perhaps even understand them, thus they act out with distressed behaviors. The cause of these symptoms is often multifactorial and often related to the environment or to another medical etiology. Several innovative nonpharmacologic strategies have been studied, with many showing a significant amount of benefit when individualized approaches are implemented. Behavior diaries constructed by the caregiver and/or family are enormously helpful in devising an individualized treatment plan that not only addresses the patient s specific needs but also makes the best use of nursing resources. Pharmacologic treatment of neuropsychiatric and behavior symptoms should be a last resort. Although medications may be temporarily effective, they do not address the source of the problem, which is often multifactorial. 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