CHAPTER 31—BEHAVIORAL PROBLEMS IN DEMENTIA
ASSESSMENT AND DIFFERENTIAL DIAGNOSIS
TREATMENTS FOR SPECIFIC DISTURBANCES
Most dementias are associated with a range of neuropsychiatric and behavioral disturbances, with as many as 80% to 90% of patients developing at least one distressing symptom over the course of their illness. The development of behavioral disturbances or psychotic symptoms in dementia often precipitates nursing-home placement. These disturbances are potentially treatable, and it is vital that clinicians anticipate and recognize them early. If these symptoms become apparent, it is essential to perform a thorough evaluation of contributing factors, identify the target symptoms of treatment, and implement appropriate interventions for the patient and caregiver.
Research that compares different treatment strategies for the behavioral and psychologic symptoms of dementia is growing in response to the great need for evidence-based treatment guidelines. It is possible to draw some conclusions from randomized controlled trials of studies of medications for the treatment of depression and psychosis, but this area is still lacking rigorous studies of elderly adults with dementia. Interventions using behavioral treatment modalities have also been studied, but often in small samples and using varying methods. These studies have allowed for recommendations in many areas; however, many aspects of treatment must still draw on case reports and clinical experience.
Particularly as the dementia progresses, psychiatric symptoms may develop that take on a variety of characteristics resembling discrete mental disorders such as depression or mania; however, the course and features are more difficult to predict, and treatments are less reliably effective than when these disorders occur in younger adults without dementia. Depressive symptoms are common and often manifest as apathy or a lack of interest in previously enjoyable activities. This depressive syndrome may also include a loss of interest in self-care, eating, or interacting with peers. A propensity for irritability and impulsivity may also occur. If these features become progressive, overt hostility or violence may ensue. It is at this juncture that patients may be characterized as “agitated,” reflecting a loss of the ability to modulate their behavior in a socially acceptable way. This may involve verbal outbursts, physical aggression, resistance to bathing or other care needs, and restless motor activity such as pacing or rocking. This type of overlap across symptoms, where some are associated with a depressive disorder but others such as hostility are considered atypical, often creates a significant challenge in diagnostic labeling. In this situation, the fairly nonspecific term agitation is commonly employed to describe the patient, but it may best be accompanied by additional description as to whether the problem is accompanied by simple irritability, vocal or physical aggression, or motor disturbances.
In many cases the presence of agitation may occur concomitantly with evidence of paranoia or delusional thinking, such as a false belief that caregivers are plotting to steal one’s possessions or incur harm. When delusions occur, the patient is then characterized as suffering from “psychotic” symptoms. False perceptions such as hallucinations are another type of psychotic symptom that may accompany episodes of agitated behavior. One way to conceptualize this complex condition is to consider the term agitation as a descriptor for the presence of abnormal behavior such as aggression, while the presence of psychosis (eg, paranoid delusions) reflects the abnormal perceptions and beliefs that may lead to the agitated behavior. Depending on the degree of communication deficits in a given patient, the ability to discern the presence of psychosis is variable, and in many cases agitated behaviors may occur in the absence of clear evidence as to whether delusions or other psychoses may be precipitating the disturbance. Antipsychotic medications are commonly used in the management of agitated behaviors, with the presumption that disturbed perceptions may be underlying the problem.
Occasionally a behavioral syndrome occurs that includes features of hyperactivity, euphoric mood, and grandiose beliefs that resemble a manic episode associated with bipolar affective disorder. The features of this “manic-like” syndrome are described later in this chapter, and much like other mood symptoms in dementia, the features are similar but less predictable than those seen in younger adults and treatment strategies are more challenging. One key feature of the manic-like syndromes seen in dementia patients is the tendency to develop additional symptoms outside the typical course of a bipolar manic episode, such as agitated behaviors, defiance, and confusion.
Among the behavioral complications of dementia, the most severe disruptions in caregiving occur when patients develop physical behaviors such as hitting or wandering, or develop paranoid delusions that lead to hostility and altercations with the caregiver. Caregivers, both professional and family, may use the word agitation to describe a variety of behaviors and psychologic symptoms. The clinician must consider agitation to be a nonspecific complaint and pursue further history of the problem, including a description of specific behaviors and the time course, frequency, and severity with which they occur. Environmental precipitants such as excessive stimuli or a change in the environment such as a new roommate may induce behavioral problems. The presenting complaint may relate to internal cues such as pain, hunger, thirst, or other needs that the patient is not able to express.
The complaints from family caregivers and professional caregivers in a nursing home or assisted-living facility often arise from behavioral complications occurring during daily care that involve a resistance to bathing, dressing, or other routines. Family members may feel more overwhelmed than professional caregivers do and may consequently attribute more overall distress to these episodes. This type of overt resistance to care is most often seen in later stages of dementia, but it is important to note that behavioral problems may also be a first sign of an incipient cognitive decline in earlier stages as well. Neuropsychiatric symptoms such as apathy, poor self-care, or paranoia may be the first indication of dementia before cognitive decline is recognized, such that an evaluation for dementia in any older patient who presents with new behavioral or emotional symptoms may reveal a previously undetected dementia syndrome.
Comprehensive assessment includes a history both from the patient and from an informant or other source. The information should include a clear description of the behavior: its temporal onset, course, associated circumstances, and its relationship to key environmental factors, such as caregiver status and recent stressors. The problem behaviors and symptoms should be then considered in the context of the patient’s family, past, personal, social, and medical history.
A differential diagnosis of the disturbance should proceed on the basis of findings from a comprehensive geriatric evaluation. The first step is to decide whether the disturbance is a symptom of a new or a preexisting medical condition or a medication adverse effect. Disturbances that are new, acute in onset, or evolving rapidly are most often due to a medical condition or medication toxicity. An isolated behavioral disturbance in a demented patient can be the sole presenting symptom for acute conditions such as pneumonia, urinary tract infection, arthritis, pain, angina, constipation, or poorly controlled diabetes mellitus. Additionally, the need to satisfy basic physical needs, such as hunger, sleepiness, thirst, boredom, or fatigue, which the patient cannot adequately communicate, may precipitate a behavioral disturbance. Medication toxicity due to new or existing medications might also present as behavioral symptoms alone. Treatment or stabilization of the medical or physical cause is often sufficient to resolve the disturbance. Older adults with dementia may require several weeks longer to recover from routine medical problems than those who are cognitively intact.
The second step is to consider whether the behavioral disturbance is related to an environmental precipitant. These include disruptions in routine, time change (eg, with daylight savings time or travel across time zones), changes in the caregiving environment, new caregivers, a new roommate, or a life stressor (eg, death of a spouse or family member). Other common environmental precipitants include overstimulation (eg, too much noise, crowded rooms, close contact with too many people), understimulation (eg, relative absence of people, spending much time alone, use of television as a companion), and the disruptive behavior of other patients. For many disturbances, correcting an environmental precipitant or removing the stressor commonly improves the symptoms.
Another consideration is whether the disturbance results from stress in the patient-caregiver relationship. Caring for dementia patients is difficult and requires a degree of perseverance that most caregivers are capable of learning if proper guidance and support is provided. Inexperienced caregivers, domineering caregivers, or caregivers who themselves are impaired by medical or psychiatric disturbances may exacerbate or cause a behavioral disturbance. Caregiver burden may be a problem both in community settings and in nursing homes. It is important for the clinician to assess the level of stress and burden on the caregiver as part of the evaluation of behavioral disturbances. Interventions to improve the patient-caregiver relationship and provide caregiver education and support are a vital part of treatment of behavioral disturbances in dementia. Providing resources to caregivers such as referral to support groups and respite services is often very helpful. (See the list of resources in the Appendix.)
After medical, environmental, and caregiving causes are excluded, it might be concluded that the behavioral problem is a manifestation of the dementia and may not be amenable to a pharmacologic intervention. Such disturbances that are closely linked to the dementia syndrome take on the form of a catastrophic reaction. A catastrophic reaction is an acute behavioral, physical, or verbal reaction to environmental stressors that result from an inability to make routine adjustments in daily life. The reaction might include anger, emotional lability, or aggression when the patient is confronted with a deficit, such as the inability to find a word, or confusion about where she is or what she is supposed to do. Catastrophic reactions are best treated by identifying and avoiding their precipitants, by providing structured routines and activities, and by recognizing early signs of the impending catastrophic reaction so that the patient can be distracted and supported before reacting.
If the disturbance is not related to an identifiable cause or environmental precipitant, it may be a consequence of the brain deterioration that occurs during the course of dementia. Disturbances with a more insidious onset or that are persistent are more likely to be symptoms of the underlying disease. Epidemiologic and clinical studies suggest that such disturbances fall into three groups: mood symptoms, psychosis, and specific behaviors. The overlap in the symptoms of these groups can make treatment choices difficult. One approach for the clinician is to decide whether the predominant symptom of a polysymptomatic disturbance is psychosis (delusions or hallucinations), mood symptoms (dysphoria, sadness, irritability, lability), aggression, or agitation, and then target treatment toward the prevailing feature.
Behavioral disturbances may occur in all types of dementias, including Alzheimer’s type, vascular, and mixed. Frontotemporal dementia (Pick’s disease) is a less common type of dementia often associated with prominent disinhibition, compulsive behaviors, and social impairment due to more advanced frontal lobe degeneration. In severe cases, a syndrome of hyperphagia, hyperactivity, and hypersexuality may occur that is related to bilateral temporal lobe atrophy. Another dementia associated with prominent psychiatric symptoms and behavioral disturbances is dementia with Lewy bodies (DLB). This form of dementia may be more common than previously thought. It is characterized by cognitive deterioration and parkinsonian features with prominent psychosis characterized by visual hallucinations. Patients with DLB often suffer from distressing hallucinations and a fluctuating clinical course. These patients are extremely sensitive to the extrapyramidal side effects of antipsychotic medications (such as muscle rigidity and tremor) and often cannot tolerate even low doses of atypical agents.
The treatment of the psychiatric and behavioral disturbances in dementia is complex and may require several interventions applied as part of a comprehensive plan of care. Specialists should be consulted in refractory cases. In general, treatment begins with appropriate environmental and caregiver interventions. Nonpharmacologic interventions should always be used as a first-line treatment in the management of disruptive, aggressive, or agitated behavior. Table 31.1 provides a list of key behavioral interventions that might ameliorate behavioral symptoms in patients with dementia. The implementation of a daily routine and introduction of meaningful activities is vital. Patients with dementia may display a reduction in behavioral disturbances with the use of music, particularly during meals and bathing, and with light physical exercise or walking. Massage, pet therapy, white noise, videotapes of family, and cognitive stimulation programs may also be helpful. If the disturbances persist despite best efforts, pharmacologic interventions for specific target symptoms are often necessary. Their disorder-specific use, in conjunction with nonbiologic therapies, is discussed in the next section.
At the core of treatment is the identification of any possible underlying cause of the behavior change, with the recognition that multiple causes may be operating concurrently. First and foremost, managing pain, dehydration, hunger, and thirst is paramount. Consider the possibilities of positional discomforts or nausea secondary to medication effects, as these are common possible culprits. Environmental modifications can improve patient orientation. Good lighting, one-on-one attention, supportive care, and attention to personal needs and wants are also important aspects of treatment. If there is sleep-wake cycle disturbance, efforts should be made to stabilize the sleep cycle by maintaining a stable routine, using bright lights, or prescribing short-term use of medications (see the sleep disturbances section, below).
In dementia patients experiencing mood symptoms, procedures similar to those used with other behavior disturbances should be employed, that is, optimize the environment by reducing adversive stimuli and assess physical health comprehensively. Recreation programs and activity therapies have demonstrated positive results in improving mood in depressive symptoms in dementia. Criteria for the diagnosis of depression in Alzheimer’s dementia have been proposed that note common features of irritability and social isolation or withdrawal. The waxing and waning course of mood symptoms in dementia is attributed to the cognitive loss and reduction in communication skills related to the dementia. Depression of 2 weeks’ duration resulting in significant distress should likely receive a trial of an antidepressant medication. Similarly, sustained depressive features lasting more than 2 months following the initiation of behavioral interventions warrants treatment with antidepressant medications.
First-line agents are the selective serotonin-reuptake inhibitors, preferred for their favorable side-effect profiles. Studies of depression in patients with dementia have demonstrated the efficacy of sertraline and citalopram in comparison with placebo, but other studies using the same medications as well as paroxetine and fluoxetine have been inconclusive. Table 31.2 lists the antidepressants most commonly used to treat depressive symptoms in dementia.
The treatment of depression in dementia requires persistence. If a first agent has failed an adequate therapeutic dose for 8 to 12 weeks, an alternative agent should be tried. Venlafaxine, bupropion, mirtazapine, and the tricyclic agents desipramine and nortriptyline might be considered. Tricyclics should be avoided if a bundle branch block or other significant cardiac conduction disturbance is present. For patients who are partial responders to an antidepressant, augmentation strategies might be considered. The addition of a stimulant such as methylphenidateOL (2.5 to 10 mg per day) may be helpful in some cases, but there is some risk of increasing psychotic symptoms if the patient has a tendency to be suspicious or delusional. Also, the addition of stimulants such as methylphenidate to augment bupropion should be avoided, as bupropion already possesses stimulant effects. If the patient does not improve, the agents should be discontinued. If a patient continues to be significantly depressed after several antidepressant trials and is in danger because of serious weight loss or suicidal ideas, electroconvulsive therapy might be considered. This is the most efficacious and rapidly effective treatment for severe major depression and has a favorable safety profile even in mild dementia.
Occasionally mood syndromes may develop in dementia patients that are characterized by pressured speech, disinhibition, elevated mood, intrusiveness, hyperactivity, and reduced sleep. These syndromes therefore resemble manic episodes observed in the context of bipolar affective disorder in younger adults, although they are generally considered to be secondary to the dementing disorder. The important distinction in the dementia patient is the frequent co-occurrence with confusional states and a tendency to have more of a fluctuating mood, that is, the patient’s mood may be irritable or hostile as opposed to euphoric. The appearance of hypersexual behaviors may be observed in this clinical scenario, although sexual disinhibition frequently occurs with dementia as a consequence of reduced frontal-executive functioning and may not necessarily be part of a manic syndrome. Treatment of manic-like states, emotional lability, disinhibition, or irritability typically begins with the use of mood-stabilizing agents such as divalproex sodiumOL (see Table 31.3). The sustained-release preparation divalproex sodium is commonly recommended. In dementia patients, a typical starting dose of divalproex is 125 mg twice a day. The dose should be titrated upward slowly while the patient is monitored for sedation, ataxia, and falls. Blood levels in the range of 40 to 100 μg/dL have been shown to be effective, but individual variability in dose and response is great. Because of the potential adverse effects on the liver and thrombocytopenia, transaminase levels and a complete blood cell count (CBC) should be taken before therapy is initiated, rechecked with each dose increase, and repeated at least every 6 months while the patient remains on the drug. Alternatives to divalproex sodium are carbamazepineOL, lamotrigineOL, or lithiumOL. Carbamazepine starting at 100 mg twice a day (with monitoring of liver enzymes and CBC) is an acceptable alternative for manic-like states, mood lability, or irritability in dementia. Leukopenia is of concern with carbamazepine, and monitoring the CBC with every dose increase and at least every 3 months while the patient remains on the drug is needed. Lamotrigine has been used in the treatment of mania, but no geriatric trials have been conducted. Lithium is valuable as a mood stabilizer, but its use may be a problem in the elderly patient because of enhanced sensitivity to adverse effects. Elevated lithium levels may occur in the context of reduced renal function and dehydration, resulting in ataxia, tremor, gastrointestinal distress, and confusion.
Delusions (paranoid or unfounded ideas) or hallucinations (false perceptions), whether occurring independently or in association with mood syndromes, typically require specific pharmacologic treatment if the patient is disturbed by these experiences, or if the experiences lead to disruptions in the patient’s environment that cannot otherwise be controlled. Clinical criteria for the diagnosis of Alzheimer’s dementia with psychosis specifies that the presence of delusions or hallucinations occur for at least 1 month, at least intermittently, and must cause distress for the patient. Antipsychotic drugs are listed in Table 31.4, along with dosing information. The atypical agents risperidoneOL, olanzapineOL, quetiapineOL, and aripiprazoleOL are being used more commonly than older agents such as haloperidolOL. The older agents are more likely to cause extrapyramidal side effects, such as parkinsonism and tardive dyskinesia. Sedation, hypotension, and falls are common adverse effects among all antipsychotic agents. As these medications are more widely used, differences in side-effect profile are emerging. An increased risk of cerebrovascular events in patients with dementia has been identified with use of risperidone, olanzapine, and aripiprazole. The U.S. Food and Drug Administration (FDA) has required that warnings regarding diabetes mellitus, hyperglycemia, ketoacidosis, and hyperosmolar states be included as a risk of therapy with all of the atypical antipsychotic agents. Quetiapine is the most sedating of the atypical agents. ClozapineOL, the first atypical agent introduced, is difficult to use because of the need for weekly CBC monitoring, adverse effects of sedation and orthostatic hypotension, and the risk of agranulocytosis. Clozapine is still helpful in a small group of patients with psychosis associated with Parkinson’s dementia and those with DLB who are unable to tolerate the extrapyramidal adverse effects of other agents. It is clear that more information on side effects of all atypical agents will become available and should be considered by the clinician before prescribing them.
Although antipsychotic agents have demonstrated efficacy in large controlled trials in the treatment of dementia with psychosis and aggression, it is important to note that the overall positive effects have been relatively modest. Controlled studies of geriatric patients have had notorious difficulty with very high placebo responses. Although 45% to 55% of patients have been found to improve on antipsychotic medications, the response to placebo ranged from 30% to 50% across studies. Antipsychotic agents clearly play an important role in the treatment of delusions, hallucinations, and aggression in dementia, but they must be part of a comprehensive treatment plan. The FDA has requested that the manufacturers of aripiprazoleOL, olanzapineOL, quetiapineOL, risperidoneOL, clozapineOL, and ziprasidoneOL add a boxed warning to their labeling describing an increased risk of mortality that has been observed in 17 placebo-controlled studies. In these studies, the rate of death for patients with dementia was approximately 1.6 to 1.7 times that of placebo. In most cases the cause of death appeared to be heart related or from infections (eg, pneumonia). More information on this warning is available at http://www.fda.gov/cder/drug/infopage/antipsychotics/default.htm.
There is some evidence that cholinomimetic agents such as donepezil or galantamine may reduce the psychosis and behavioral disturbances of Alzheimer’s disease. Studies comparing these agents with placebo in patients with mild to moderate Alzheimer’s disease have suggested that they may reduce the rate of emergence of behavioral disturbances and psychosis. One area where cholinesterase inhibitors may be likely to improve psychosis is in the case of DLB; reduced visual hallucinations have been reported with cholinesterase inhibitors. Galantamine in dosages of 16 to 24 mg per day may be useful in the treatment of patients with DLB, who are uniquely sensitive to the extrapyramidal adverse effects of antipsychotic agents.
Treatment of insomnia and sleep-wake cycle disturbance should begin with improvement of sleep hygiene (see Table 31.5). This consists of efforts to get the patient to go to sleep later every day, around 10:00 or 11:00 pm, while keeping the environment calm, comfortable, and conducive to sleep, into the next morning. If the sleep disturbance is associated with depression, suspiciousness, or delusions, those conditions should be treated.
For primary sleep disturbances when good sleep hygiene and increasing daytime activity level are not successful, trazodoneOL (25 to 150 mg at bedtime) or mirtazapineOL (7.5 to 15 mg at bedtime) might be used. Benzodiazepines or antihistamines, such as diphenhydramine, should be avoided, since they carry a high risk for falls, hip fractures, disinhibition, and cognitive disturbance when prescribed for patients with dementia. (See also Sleep Problems.)
ZolpidemOL and zaleplonOL are short-acting nonbenzodiazepine sedative hypnotics that may be helpful for sleep disturbances in the elderly patient, although there have been no controlled trials for their use in sleep disturbances secondary to dementia. Zolpidem has been studied in elderly patients without dementia and appears to be effective in improving sleep onset, although it does not improve sleep duration because of its short half-life. The recommended dose of zolpidem in the elderly person is 5 mg, as an increased risk of adverse effects appears to be dose related. Zaleplon has been less extensively studied in the older patient but appears to have similar properties.
If hypersexuality occurs in association with another recognizable syndrome such as a mania-like state, treatment of the specific syndrome should be attempted. In men with dementia who are dangerously hypersexual or aggressive, a trial of an antiandrogen might be attempted to reduce the sexual drive. Patients may be tried on progesteroneOL 5 mg orally once daily at first. The dose should be adjusted to suppress serum testosterone well below normal. If the patient responds well behaviorally, 10 mg of depot intramuscular progesterone may be given weekly to maintain a reduction of sexual drive. An alternative treatment to reduce sexual drive is leuprolide acetateOL (5 to 10 mg intramuscularly every month), also an antiandrogen. The use of antipsychotic medications is often adopted clinically, given the seriousness of hypersexual behaviors in institutionalized setting such as nursing homes; however, there are no controlled studies supporting this use. Presumably, the medication may enhance the cognitive focus of the individual’s perceptions by reducing any psychotic thinking that may in some way be contributing to hypersexual behavior. Additional studies are needed for this problem.
When disruptive behavior occurs intermittently or episodically, such as once per week or less, behavioral interventions focusing on identifying the antecedents of the behavior and avoiding the triggers are often most useful. Behavior modification using positive reinforcement of desirable behavior has been shown to be helpful, and it also helps encourage the caregiver to focus on times when behavior is not a problem. Reminiscence, validation therapy, aromatherapy, and environmental modifications of light, sound, and space may all help promote positive behavior. Distraction techniques, activity therapies, and exercise also show promise in reducing troublesome behaviors.
Physical restraint in any form should be avoided if at all possible. If restraining measures are necessary, careful supportive care should be provided to the patient. Over time, it is usually possible to reduce or eliminate the amount of restraint. (See also the section on quality issues in Nursing-Home Care, and the section on restraints in the nursing home in Legal and Ethical Issues.)
■ American Psychiatric Association. Practice guideline for the treatment of Alzheimer’s disease and other dementias of later life. Am J Psychiatry. 1997; 154(5 Suppl):1–39.
This practice guideline by the American Psychiatric Association remains the standard reference for evidence-based treatment of Alzheimer’s dementia. It discusses in depth the evidence for and against various therapies for Alzheimer’s disease and related conditions. This small supplement to a main issue of the journal provides a ready reference for clinicians.
■ Doody RS, Stevens JC, Beck C, et al. Practice parameter: management of dementia (an evidence-based review). Report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2001;56(9):1154–1166.
This standard of care provided by a consensus committee of the American Academy of Neurology covers all aspects of dementia care, including interdisciplinary assessment and care planning and caregiver support. This is a well-balanced review that assigns a level of recommendation for each treatment (standard, guideline, or option) on the basis of the type of evidence provided (ranging from meta-analyses of randomized controlled trials, observational studies, and expert opinions to case series and studies).
■ Lyketsos CG, Sheppard JM, Steele CD, et al. Randomized, placebo-controlled, double-blind clinical trial of sertraline in the treatment of depression complicating Alzheimer’s disease: initial results for the Depression in Alzheimer’s Disease study. Am J Psychiatry. 2000;157(10):1686–1689.
This is the first randomized controlled trial of antidepressant efficacy in persons with Alzheimer’s disease and major depression. It demonstrates benefits similar to those seen in persons with major depression and no dementia.
■ Snowden M, Sato K, Roy-Byrne P. Assessment and treatment of nursing home residents with depression or behavioral symptoms associated with dementia: a review of the literature. J Am Geriatr Soc. 2003;51(9):1305–1317.
This comprehensive review critically assesses all studies from 1970 to the present of the treatment of behavioral and psychologic symptoms of dementia in the nursing home. Neither pharmacologic nor behavioral interventions eliminate problem symptoms, but both offer a reduction in intensity and severity. This thorough review provides a basis upon which to begin an evidenced-based approach to the treatment of behavioral symptoms in dementia, and it highlights studies by strength of design.
■ Steinberg M, Sheppard JM, Tschanz JT, et al. The incidence of mental and behavioral disturbances in dementia: the Cache County study. J Neuropsychiatry Clin Neurosci. 2003;15(3):340–345.
This paper provides longitudinal data on the new and cumulative incidence of mental and behavioral symptoms in a sample of patients with dementia followed over an 18-month period. The cumulative prevalence of all symptoms approached 90%; delusions were most common (28%), followed by apathy (21%) and aberrant motor behavior (21%). This well-conducted study reveals both the high incidence rate of behavioral and psychologic disturbances (61%) and suggests that all patients with dementia be assessed for the presence of behavior symptoms as part of routine evaluation.
■ Tariot PN, Ryan JM, Porsteinsson AP, et al. Pharmacologic therapy for behavioral symptoms of Alzheimer’s disease. Clin Geriatri Med. 2001;17(2):359–376.
This practical review offers the clinician an approach to the use of psychotropic medications for specific target symptoms in dementia. The monitoring of side effects and the use of clinical outcome measures are discussed.
■ Weiner MF, Lipton AM, eds. The Dementias Diagnosis Treatment and Research. 3rd ed. Washington DC: American Psychiatric Press, Inc.; 2003.
This thorough text serves as both a reference and clinical guide to all aspects of dementia care. This book provides an update on dementias of all types, including Alzheimer’s, vascular, fronto-temporal, and Lewy body. Recommendations for clinical management and evidenced-based guidelines are provided. It includes rating scales, assessment tools, and resources for the practitioner and caregiver.
Melinda S. Lantz, MD
Constantine G. Lyketsos, MD, MHS