Pharmacologic Treatment of Agitation and Apathy in Dementia
Alzheimer’s disease (AD) is the most common cause of dementia, affecting nearly 18 million people around the world. Alzheimer’s disease is characterized by cognitive, functional, and behavioural decline. As the condition progresses the affected individual becomes increasingly dependent on others for assistance in performing all activities of daily living. Neuropsychiatric symptoms (NPS) such as agitation, psychosis, and apathy are very common in dementia and especially in AD. Agitation and apathy contribute to a tremendous amount of caregiver distress. Treatment guidelines recommend utilizing nonpharmacologic behavioural approaches in all instances. When behavioural interventions fail or when the behaviour is severe, medications are recommended. At present, no psychotropic agent presently available within the United States is FDA-approved for use in dementia complicated with behaviour disturbance.
Key words: agitation, apathy, behaviour interventions, atypical antipsychotics, dementia.
Introduction
Neuropsychiatric symptoms (NPS) also known as behavioural and psychological symptoms of dementia (BPSD) are common and have been reported in more than 80% of subjects in most studies.1 These features of the disorder contribute to poor outcomes for individuals with dementia and their caregivers, and may include depression, agitation, aggression, apathy, hallucinations, and delusions. Neuropsychiatric symptoms are commonly seen with various types of dementia including Alzheimer’s disease, vascular dementia, Lewy body dementia, and frontotemporal dementias. This review will focus on the treatment of agitation and apathy in Alzheimer’s disease.
Agitation
Inappropriate behaviours are defined as verbal, vocal, or motor activities not judged to be clearly a consequence of the needs of the individual or the requirements of the situation.2 Inappropriate behaviours can be divided into four categories: physically aggressive behaviours (e.g., hitting, kicking, biting); physically nonaggressive behaviour (e.g., pacing or inappropriate touching); verbally nonaggressive agitation (e.g., repetitive phrases or demands); and verbally aggressive behaviours (e.g., cursing or screaming).
Lyketsos and colleagues3 reported findings from a study of 5,092 community residents who represented 90% of the older adult population of Cache County in Utah, USA. Several disturbances (delusions, anxiety, apathy, irritability, elation, and disinhibition) were reported with similar severity at all stages of dementia. In contrast, aggression/agitation and aberrant motor behaviour (restlessness and pacing) were more common at later stages of dementia. The study also identified a slightly increased occurrence of depression and hallucinations in moderately severe dementia as compared to mild stage dementia.
Assessment of the Individual with Agitation in Dementia
Psychiatric assessment of the individual with dementia complicated by agitation involves a thorough search for all biological, psychological, social, and environmental factors that may contribute to the disturbed behaviour. Assessment involves a comprehensive review of medical records, interview of the caregivers, and a physical and mental status examination of the patient. The assessment is focused on ruling out underlying medical etiologies (e.g., urinary tract infection) in an effort to rule out delirium, and looking for any environmental factors that could have triggered the symptoms. Important evaluation components include a pain assessment, exploration of sensory deficits, investigation of drug interactions and side effects, and a determination of whether the NPS represent an unmet physical need (e.g., hunger, need to void, or feeling too hot or cold).
Treatment of Agitation in Dementia
Initially, behaviour