Behavioral management techniques–including specific types of training for caregivers on managing neuropsychiatric symptoms–and cognitive stimulation therapy are the most effective treatments for neuropsychiatric symptoms of dementia, Dr. Constantine G. Lyketsos reported at the Copper Ridge Institute in Sykesville, Md.
Dr. Lyketsos, codirector of the division of geriatric psychiatry and neuropsychiatry at Johns Hopkins University, Baltimore, and academic director at Copper Ridge, summarized results of a systematic review of literature on psychological approaches to dementia treatment reviewed as part of a Grand Rounds lecture at the institute.
In explaining dementia, which involves loss in memory, judgment, and abstract thinking, Dr. Lyketsos pointed out that the noncognitive neuropsychiatric symptoms (NPS) of dementia give caregivers the most concern and also often result in placement of the patient in long-term care facilities.
Prevalence of NPS in Dementia
In a cross-sectional study derived from the Cardiovascular Health Study, Dr. Lyketsos and his associates found that 43% of participants with dementia exhibited clinically significant NPS in the month prior to their participation in the study, and more than 80% exhibited NPS sometime after the onset of cognitive impairment (JAMA 2002;288:1475–83).
NPS adversely affect day-to-day functioning and cause decreased quality of life for the patient. The symptoms also contribute significantly to caregiver burden and add approximately $10,000 per year of additional cost per patient, according to Dr. Lyketsos.
The most common NPS include affective disturbances such as depression, anxiety and irritability; psychotic disturbances such as delusions and hallucinations; specific behaviors such as wandering and aggression/agitation; and disturbances of drives related to sleep, eating, and sexuality.
Neuropsychiatric symptoms in patients with dementia may be caused by underlying brain damage, medication side-effects, medical illness, environmental stressors, cognitive symptoms such as executive dysfunction, unsophisticated caregiving, unmet physical needs, and unmet psychological needs.
Psychotropic Medication Use
The most treatable symptoms of dementia are neuropsychiatric symptoms, Dr. Lyketsos said.
NPS often are treated with psychotropic medications, but the safety and efficacy of these medications have been questioned. In a comprehensive, systematic review of pharmacological interventions for neuropsychiatric symptoms of dementia, Dr. Kaycee M. Sink and associates said pharmacological therapies are not particularly effective for management of neuropsychiatric symptoms of dementia (JAMA 2005;293:596–608).
In a separate study, Dr. Lon S. Schneider and colleagues assessed the evidence for efficacy and adverse events of atypical antipsycothics for people with dementia and found that the atypical antipsychotics risperidone and aripiprazole showed evidence of efficacy for NPS but increased risk for cerebrovascular events, especially with risperidone (Am. J. Geriatr. Psych. 2006;14:191–210). As a result, the researchers suggested that nonpharmacologic interventions should be attempted before moving to drug therapy for NPS.
Nonpharmacologic Treatment
Dr. Gill Livingston and associates systematically reviewed the literature on psychological approaches to neuropsychiatric symptoms. They summarized and classified studies that used evidence-based guidelines to help clinicians understand which interventions are effective in the short or long term (Am. J. Psych. 2005;162:1996–2021).
Each type of intervention–reminiscence therapy, validation therapy, reality orientation therapy, cognitive stimulation therapy, music therapy, Snoezelen therapy, therapeutic activity programs, and behavioral management techniques–was given an overall grade base on the Oxford Centre for Evidence-Based Medicine criteria. (See table at right.)
The grades ranged from A (consistent level of evidence) to D (troublingly inconsistent or inconclusive). The researchers noted, however, that “conclusions are limited because of the paucity of high-quality research” in this area.
There is need for more randomized, controlled trials and the use of standard interventions, Dr. Livingston and her associates said. The lack of evidence of the efficacy of a particular treatment does not mean it is not an effective treatment.
Effective Psychological Therapies
Dr. Livingston's review showed that behavioral management therapies centered on individual patient behavior or on caregiver behavior are generally successful for decreasing NPS, and the results are effective for months.
Specific types of psychoeducation for residential care staff and caregivers on managing neuropsychiatric symptoms were effective in the long term, especially when provided to individuals rather than in group settings.
Cognitive stimulation therapy (CST), which uses information processing rather than factual knowledge, showed early behavior improvements. An example of CST is a “faces” activity, which involves asking patients to choose the youngest looking face in a set, or to determine what the faces have in common.
Dr. Charles Cefalu, professor and chief of geriatric medicine at Louisiana State University, New Orleans, said wandering is the most troubling symptom in persons with dementia for caregivers and nursing home staff.
He also said that the best way to treat wandering in a nursing home is by having a closed Alzheimer's unit.