An 84-year-old man is brought to the office by his daughter for increased confusion and agitation. He has a history of moderate Alzheimer dementia with worsening cognitive and functional status over the past 6 months. He now requires 24-hour supervision that involves shifts of family members and caregivers. The daughter notes that the patient frequently wanders and has been more restless and agitated, especially in the evenings. He frequently yells when he can't find misplaced objects. He is increasingly paranoid and accuses the caregivers of stealing his money and important papers. The patient has no pain or discomfort. Medications include donepezil, multivitamins, tamsulosin, and acetaminophen.
Vital signs are within normal limits. Physical examination is unremarkable. The patient is oriented to person and recognizes his daughter but is disoriented to time and place. He recalls 0 of 3 objects after 5 minutes.
Complete blood count and comprehensive chemistry panel are within normal limits.
Which of the following is the most appropriate next step in management of this patient's neuropsychiatric symptoms?

Question

An 84-year-old man is brought to the office by his daughter for increased confusion and agitation.  He has a history of moderate Alzheimer dementia with worsening cognitive and functional status over the past 6 months.  He now requires 24-hour supervision that involves shifts of family members and caregivers.  The daughter notes that the patient frequently wanders and has been more restless and agitated, especially in the evenings.  He frequently yells when he can't find misplaced objects.  He is increasingly paranoid and accuses the caregivers of stealing his money and important papers.  The patient has no pain or discomfort.  Medications include donepezil, multivitamins, tamsulosin, and acetaminophen.
Vital signs are within normal limits.  Physical examination is unremarkable.  The patient is oriented to person and recognizes his daughter but is disoriented to time and place.  He recalls 0 of 3 objects after 5 minutes.
Complete blood count and comprehensive chemistry panel are within normal limits.
Which of the following is the most appropriate next step in management of this patient's neuropsychiatric symptoms?

Quizplus · Accepted Answer

Neuropsychiatric symptoms such as agitation, aggression, paranoid delusions, hallucinations, and wandering are very common in patients with Alzheimer dementia. These symptoms typically increase with dementia severity and are worse in the evening (sundowning). They cause distress for patients and caregivers and may lead to nursing home placement. Nonpharmacologic interventions are preferred for the initial management of neuropsychiatric symptoms: Behavioral methods include establishing structured routines, using distraction and redirection, and identifying and avoiding environmental triggers that cause agitation (eg, sudden change in surroundings). Environmental therapy (eg, exercise, music therapy, touch therapy, removing offending stimuli), combined with caregiver education (eg, teaching family members structured routines, providing reassuring responses), also helps to diminish agitation. Behavioral methods include establishing structured routines, using distraction and redirection, and identifying and avoiding environmental triggers that cause agitation (eg, sudden change in surroundings). Environmental therapy (eg, exercise, music therapy, touch therapy, removing offending stimuli), combined with caregiver education (eg, teaching family members structured routines, providing reassuring responses), also helps to diminish agitation. Pharmacotherapy is reserved for patients with severe symptoms who do not respond to nonpharmacological interventions or when agitated behavior poses a safety risk to self or others. (Choice A) Although memantine may have modest benefits for cognition in patients with moderate to severe Alzheimer dementia, there is no evidence of a clinically significant effect for neuropsychiatric symptoms of dementia. (Choice C) Benzodiazepines should be avoided in Alzheimer dementia due to significant side effects (eg, sedation, confusion, worsening gait and falls, paradoxical agitation, physical dependence). (Choice D) Low-dose antipsychotics have limited efficacy and are associated with increased mortality in elderly patients with dementia. They should be reserved for cases in which other interventions fail or when neuropsychiatric symptoms result in severe distress or safety risks. Nonpharmacological strategies should be tried first in this patient whose symptoms are not severe or threatening to caregiver safety. (Choice E) Antidepressants have not shown consistent efficacy for neuropsychiatric symptoms of dementia other than depression. Selective serotonin reuptake inhibitors may be considered if nonpharmacological interventions are ineffective and there is concern that the patient's agitated behavior may be related to a poorly verbalized mood disturbance. Educational objective: Nonpharmacologic therapies (eg, environmental, behavioral) are first-line interventions in dementia patients with behavioral disturbances. Antipsychotics are not consistently effective and should be reserved for patients who do not respond to nonpharmacological interventions or when agitated behavior poses a safety risk to the patient or caregivers. __________ References: Nonpharmacologic management of behavioral symptoms in dementia. (http://www.ncbi.nlm.nih.gov/pubmed/23168825) Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/25452601)

An 84-Year-Old Man Is Brought to the Office by His