This article discusses the assessment and treatment of BDD. Although the primary focus is on pharmacological therapy, it should be recognized that medications should be considered only after environmental and behavioral management are optimized.
Symptoms by Stage
Virtually any psychiatric symptom can occur in patients with BDD. Complex combinations of symptoms are common, and these evolve over time. Symptoms might or might not resemble typical psychiatric syndromes.
Approximately five million Americans currently suffer from Alzheimer’s disease (AD) and other forms of dementia. This figure is rapidly growing as the elderly population increases. Along with a rising number of elders, a longer life span is leading to a larger group of people over 85 years of age who are at the highest risk of developing dementia. The number of person with dementia in the U.S. may reach 16 million or more over the next 25 years. Most people with dementia have some form of psychiatric or behavioral disturbance during the course of their disease. Up to 50% of these people are believed to have psychotic symptoms, including delusions and hallucinations. Despite these problems, behavioral disturbance in dementia (BDD) has not been a major focus of psychiatric research.
Behavioral disturbance contributes greatly to a reduced quality of life for patients, their caregivers, and those around them. Hospitalization and placement of the patient in a long-term care facility are often prompted by BDD. Therefore, BDD drives much of the cost of caring for these patients. As the problem becomes more prevalent, the most severely disturbed patients move back and forth between the hospital and nursing home in a new kind of “revolving door.” In the typical nursing home, approximately 50% of patients are affected by dementia. Nursing homes are becoming de facto psychiatric facilities in the management of BDD, a role that they were not designed to play.
In early or mild dementia, increased anxiety or mood changes frequently occur and may actually predate the onset of diagnosable symptoms of dementia relating to memory. Various psychiatric manifestations characterize each stage of dementia (Table 1). As dementia progresses through its stages, the earlier symptoms may persist while new ones develop.
Moderate dementia is often a challenging period in the management of BDD. Wandering, sleep disturbances, agitation, aggression, and combativeness may occur. Yelling or other vocalization syndromes present significant challenges (e.g., chanting, repeatedly asking the same question).
Psychosis often begins and usually includes an element of paranoia, often focused on the caregiver or on those nearby. When patients no longer recognize loved ones, the paranoia may take the form of delusions such as thinking that the loved ones are impostors.
Table 1 Behavioral and Psychiatric Symptoms of Dementia by Stage
|Agitation and aggression|
|Mood symptoms, apathy|
|Refusal of health care services|
|Lack of self-care|
|Inappropriate sexual behavior|
|Adapted from American Psychiatric Association (APA).|
|Am J Psychiatry 1997;154(5 Suppl):l-39.|
Hallucinations are less common, but they may be noted in Lewy body and other parkinsonian dementias as well as in delirium. Hallucinations are predominantly visual. Because of memory disturbance, confabulation, and communication deficits, psychosis can be difficult to diagnose in patients with dementia. As dementia progresses, sleep usually becomes more erratic. Patients might not perceive this as a problem, but it is a significant challenge for caregivers. Some patients become more agitated or psychotic at night, a condition sometimes known as “sundowning.” Disinhibition and inappropriate sexual behaviors may also occur.
In late-stage dementia, agitation and aggression may be ongoing problems. Apathy, refusal of health care services, and eating problems may ensue. In addition, behavioral patterns typical of infancy or childhood may re-emerge.
The etiologic mechanism of BDD is not well understood. BDD is almost certainly a heterogeneous, multifactorial problem. Pre-existing psychiatric illness such as affective disorder, schizophrenia, or substance abuse may be a contributing factor in some cases. Some symptoms, such as anxiety, may be a direct result of cognitive loss.
Dementia frequently contributes to stressful life situations such as loss of independence and placement in a nursing home. Patients with dementia often deal with such stressors by acting out behav-iorally. Many symptoms undoubtedly follow as a direct result of neurodegeneration. Dementing illnesses lead to changes in levels of acetylcholine, norepinephrine, and serotonin, the key neuro-transmitters that affect thinking and behavior.
Table 2 Features of Delirium
Common in dementia patients
Provoked by comorbid medical problems (often systemic rather than CNS-based) or medications Multiple contributing factors often involved Urinary tract infection, medication often involved in dementia/delirium
Time course usually acute (influenced by course of underlying comorbid medical conditions) Often recurrent
Symptoms include increased confusion, psychomotor agitation or withdrawal, altered sensorium, psychosis, sleep disturbances
Treatment primarily involves addressing underlying medical conditions
Delirium resulting from comorbid medical conditions or from medications frequently contributes to BDD (Table 2). Loss of hearing or of vision may exacerbate confusion. Pain or physical discomfort can also contribute to problem behaviors, complicated by the patient’s difficulty with communication.
Table 3 Common Anticholinergic Medications and Dementia
The treatment of BDD must follow from an extremely thorough assessment of the patient. The evaluation includes screening for medical conditions that may be a source of delirium or pain. The patient’s entire medication list, including over-the-counter drugs, must be scrutinized. Polypharmacy is common among elderly patients and is frequently a source of confusion or behavioral disturbance. Patients are particularly susceptible to negative effects from anticholinergic medications. Benz-tropine (Cogentin, Merck), tricyclic antidepressants, diphenhydramine (Benadryl, Johnson & Johnson), and many others have significant anti-cholinergic effects (Table 3). The patient’s environment may also be an important factor in the development of BDD.