Patients with dementia may experience many symptoms, usually in the context of an incurable disease. Because treatment cannot address all of these symptoms, it is important to have a specific goal or goals in mind when therapy is initiated.
Because the disease provokes strong emotional reactions in caregivers and often precipitates conflict over diagnosis or treatment, it is useful to try to achieve some consensus among the primary people involved in determining the goals and means of treatment. It is often helpful to choose one or more “target symptoms” (i.e., those that are amenable to pharma-cotherapy). In most cases, reducing the intensity of symptoms is a more realistic goal than completely eradicating a behavior al problem.
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Providing a means of quantifying the symptom and response is also necessary, because caregivers’ impressions may be at odds with those of others and may be greatly influenced by their emotional response to the patient’s illness. Medication therapy is best regarded as an adjunct to nonpharmacological treatments that focus on modifying the patient’s environ-ment.
The U.S. Food and Drug Administration (FDA) has not yet approved any medication specifically for treating BDD. Therefore, pharmacotherapy for BDD, other than dementia-specific drugs such as cholinesterase inhibitors and memantine (Namenda, Forest) is “off-label.” In such situations, physicians must be aware of the heightened requirements for documenting the rationale for the treatment and monitoring of adverse events. Informed consent, usually involving a surrogate rather than the patient alone, is required.
The choice of a pharmacological agent is largely empirical. The clinician attempts to match the drug to the target symptoms to be treated. However, medication effects are often nonspecific and highly variable among patients. The drug should be initiated at the lowest dose and gradually escalated to the dose required to manage the symptoms. Most patients with BDD can be managed with low doses of medication, but individual patients may require higher levels. Polypharmacy should be minimized. Clinicians must be alert to the possibility of side effects, which may be obvious (e.g., sedation, extrapyramidal symptoms, ataxia) or subtle (e.g., apathy, swallowing difficulties).
Patients are at risk for treatment-induced delirium, which may be mistaken for the symptoms of BDD itself. The full effects of a new medication may take many weeks to be completely manifest. The overall goal of treatment is improved quality of life for the patient and caregivers rather than “cure” of the disease. Sedation is rarely a goal of treatment and typically reduces quality of life. Instead, reduction of agitation without undue sedation is desirable. Polypharmacy, rapid dose titration, and frequent medication changes can all contribute to poor outcome s.
Medication management in dementia presents significant ethical challenges. At times, the interests of patients might not be identical to those of caregivers or others. For instance, providing the patient with sedation for sleep enables the caregiver to rest as well, even though patients might not perceive their sleep deficit as a problem. The nature of dementia often prevents patients from participating in such discussions.
Careful, ongoing monitoring is required for the pharmacological management of BDD. Behavioral symptoms evolve over time, necessitating changes in medication therapy. Especially close monitoring is required after a new treatment or dose change is implemented.
After the medication doses have been stabilized, patients should be evaluated at regular intervals. Medications should be reviewed approximately every three months. When symptoms abate, health care providers should consider tapering and eventually stopping psychiatric medications.
Medications Indicated for Alzheimer’s Disease
Cholinesterase inhibitors as well as memantine have been shown to affect behavior as well as cognition in patients with Alzheimer’s disease (AD) (Table 4). These effects have been identified in a wide range of BDD symptoms.
Table 4 Drugs Indicated for Alzheimer’s Disease
N-methyl-D-aspartate (NMDA) receptor antagonist Generally, symptoms of BDD are lessened in patients with AD who are taking these medications. These symptoms may be less likely to emerge in treated patients (treatment-emergent effects). However, for patients who already have significant BDD, these medications are usually not sufficient. Overall, the effects of these medications on symptoms of BDD are worthwhile but relatively modest.
The cholinesterase inhibitors galantamine (Razadyne, Ortho-McNeil) and rivastigmine tartrate (Exelon, Novartis) are indicated for mild-to-moderate AD, whereas donepezil (Aricept, Eisai/Pfizer) is indicated for mild, moderate, or severe disease. Memantine (Namenda) is indicated for moderate-to-severe AD and may be used alone or in combination with a cholinesterase inhibitor.