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Behavioral and Psychiatric Symptoms

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Page outline

> Overview
> Medical evaluation
> Non-drug interventions
> Drug treatments
> Managing an episode
> Preventing agitation


When Alzheimer’s disrupts memory, language, thinking and reasoning, these effects are referred to as “cognitive symptoms” of the disease. The term “behavioral and psychiatric symptoms” describes a large group of additional symptoms that occur to at least some degree in many individuals with Alzheimer’s. In early stages of the disease, people may experience personality changes such as irritability, anxiety or depression. In later stages, other symptoms may occur, including sleep disturbances; agitation (physical or verbal aggression, general emotional distress, restlessness, pacing, shredding paper or tissues, yelling); delusions (firmly held belief in things that are not real); or hallucinations (seeing, hearing or feeling things that are not there).

Many individuals with Alzheimer’s and their families find behavioral and psychiatric symptoms to be the most challenging and distressing effects of the disease. These symptoms are often a determining factor in a family’s decision to place a loved one in residential care. They also often have an enormous impact on care and quality of life for individuals living in long-term care facilities.

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Medical evaluation

A person exhibiting behavioral and psychiatric symptoms should receive a thorough medical evaluation, especially when symptoms come on suddenly. Treatment depends on a careful diagnosis, determination of the possible causes, and the types of agitated behavior the person is experiencing. With proper treatment and intervention, significant reduction or stabilization of the symptoms can often be achieved.

Symptoms often reflect an underlying infection or medical illness. The pain or discomfort caused by pneumonia or a urinary tract infection can result in agitation. An untreated ear or sinus infection can cause dizziness and pain that affect behaviors. Side effects of prescription medication are another common contributing factor to behavioral symptoms. Side effects are especially likely to occur when individuals are taking multiple medications for several health conditions, creating a potential for drug interactions.

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Non-drug interventions

There are two distinct types of treatments for behavioral and psychiatric symptoms: non-drug interventions and prescription medications. Non-drug interventions should be tried first. In general, steps to managing symptoms include (1) identifying the behavior, (2) understanding its cause and (3) adapting the caregiving environment to remedy the situation.

Correctly identifying what has triggered agitated behavior can often help in selecting the best behavioral intervention. Often the trigger is some sort of change in the person’s environment:

  • change in caregiver

  • change in living arrangements

  • travel

  • hospitalization

  • presence of houseguests

  • bathing

  • being asked to change clothing

A key principle of intervention is redirecting the affected individual’s attention, rather than arguing, disagreeing or being confrontational with the person. Additional intervention strategies include the following:

  • simplify the environment

  • simplify tasks and routines

  • allow adequate rest between stimulating events

  • use labels to cue or remind the person

  • equip doors and gates with safety locks

  • remove guns

  • use lighting to reduce confusion and restlessness at night

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Medications can be effective in some situations, but they must be used carefully and are most effective when combined with non-drug approaches. Medications should target specific symptoms so their effect can be monitored. In general, it is best to start with a low dose of a single drug. People with dementia are susceptible to serious side effects, including a slightly increased risk of death from antipsychotic medications. Risk and potential benefits of a drug should be carefully analyzed for any individual. Examples of medications commonly used to treat behavioral and psychiatric symptoms include the following:

Antidepressant medications for low mood and irritability

  • citalopram (Celexa®)

  • fluoxetine (Prozac®)

  • paroxetine (Paxil®)

  • sertraline (Zoloft®)

Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance

  • lorazepam (Ativan®)

  • oxazepam (Serax®)

Antipsychotic medications for hallucinations, delusions, aggression, hostility and uncooperativeness

  • aripiprazole (Abilify®)

  • clozapine (Clozaril®)

  • olanzapine (Zyprexa®)

  • quetiapine (Seroquel®)

  • risperidone (Risperdal®)

  • ziprasidone (Geodon®)

Although antipsychotics are among the most frequently used medications for treating agitation, some physicians may prescribe an anticonvulsant/mood stabilizer, such as carbamazepine (Tegretol®) or divalproex (Depakote®) for hostility or aggression.

Sedative medications, which are used to treat insomnia or sleep problems, may cause incontinence, instability, falls or increased agitation. These drugs must be used with caution, and caregivers need to be aware of these possible side effects.

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Helpful hints during an episode of agitation

Do: back off and ask permission, use calm positive statements, reassure, slow down, use visual or verbal cues, add light, offer guided choices between two options, focus on pleasant events, offer simple exercise options, or limit stimulation.

Do not: raise voice, take offense, corner, crowd, restrain, rush, criticize, ignore, confront, argue, reason, shame, demand, condescend, force, explain, teach, show alarm, or make sudden movements out of the person’s view.

Say: May I help you? Do you have time to help me? You’re safe here. Everything is under control. I apologize. I’m sorry that you are upset. I know it’s hard. I will stay until you feel better.

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Helpful hints to prevent agitation

Create a calm environment: remove stressors, triggers or danger; move person to a safer or quieter place; change expectations; offer security object, rest or privacy; limit caffeine use; provide opportunity for exercise; develop soothing rituals; and use gentle reminders.

Avoid environmental triggers: noise, glare, insecure space, and too much background distraction, including television.

Monitor personal comfort: check for pain, hunger, thirst, constipation, full bladder, fatigue, infections, and skin irritation; ensure a comfortable temperature; be sensitive to fears, misperceived threats, and frustration with expressing what is wanted.

The Alzheimer’s Association Clinical Issues and Interventions Work Group, a team of consulting physicians and specialists, developed the content of this page.

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