RISK FACTORS : Increasing age, Prevalence of atherosclerotic disease (VaD), Trisomy 21 (Down syndrome), History of head trauma, History of CNS infection, Midlife depression
GENERAL MEASURES :
β’ Daily schedules and written directions
β’ Support and education of caregivers
β’ Emphasis on nutrition, personal hygiene, personal safety (accident-proofi ng the home) and supervision
β’ Discussions with the family concerning advanced directives
β’ Socialization (adult day care)
β’ Sensory stimulation (prominent displays of clocks and calendars)
β’ Improvement in sleep hygiene
β’ Pharmacotherapy should be reserved for specific behavioral symptoms after nonpharmacologic therapy
has failed
DRUG(S) OF CHOICE :
β’ Appropriately treat secondary causes, such as hypothyroidism or vitamin B12 deficiency
β’ With other causes, drugs are used to treat behavioral symptoms after nonpharmacologic therapy has failed
β’ Sun-downing, aggressive behavior: antipsychotics such as haloperidol (Haldol) or risperidone (Risperdal)
0.5-1.0 mg at bedtime are reasonable choices in a nonemergency situation
β’ Depression: nortriptyline (Pamelor) 20-50 mg or desipramine (Norpramin) 25 mg bid or the serotonin reuptake
inhibitors - sertraline (Zoloft), fl uoxetine (Prozac), paroxetine (Paxil), or citalopram (Celexa), escitalopram
(Lexapro)
β’ Sleep disturbance: Intermittent use of temazepam (Restoril) 15 mg, zolpidem (Ambien) 5 mg, trazodone
(Desyrel) 25-50 mg, mirtazapine (Remeron) 15 mg, or chloral hydrate 500 mg at bedtime is occasionally
warranted
β’ Cognitive dysfunction: donepezil (Aricept) 5-10 mg every AM, rivastigmine (Exelon) 1.5-6 mg bid, galantamine
(Reminyl) 4-12 mg bid, memantine (Namenda) 5-20 mg daily
CONTRAINDICATIONS:
β’ Antipsychotics (haloperidol, risperidone, thioridazine) - severe depression; Lewy body dementia, Parkinson
disease; hypo- or hypertension
β’ Tricyclic antidepressants (nortriptyline, desipramine) - acute recovery phase following myocardial infarction,
acute narrow-angle glaucoma
β’ Acute active liver disease, active untreated peptic ulcers
ALTERNATIVE DRUGS :
β’ Lithium carbonate
β’ Carbamazepine (Tegretol)
β’ Selegiline (Eldepryl)
β’ Divalproex (Depakote
PATIENT MONITORING :
β’ Periodic mental status testing to assess progression and predict prognosis
β’ Periodic monitoring of nutritional status
β’ Periodic monitoring of the caregiver status to assess for caregiver stress
β’ Periodic assessment of the environment for safety
β’ Liver function tests with tacrine therapy
POSSIBLE COMPLICATIONS :
β’ Antipsychotic-induced extrapyramidal effects
β’ Falls
β’ Pressure sores
β’ Malnutrition
β’ Constipation
β’ Various infections
EXPECTED COURSE/PROGNOSIS :
β’ AD - a progressive disease with variable rates of
progression, but inevitably leading to profound cognitive impairment
β’ VaD - less likely to be progressive but cognitive improvement is unlikely
β’ Secondary dementias - treatment of the underlying condition may lead to improvement
AGE RELATED FACTORS :
β’ In the elderly, begin drugs with small doses and increase slowly
β’ Drugs with a long half-life (fl uoxetine, lorazepam, etc.) require closer monitoring in the elderly; it may be better to choose a drug with a shorter half-life (sertraline, paroxetine, temazepam