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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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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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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 persons
A key principle of intervention is redirecting the affected
individuals 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
use lighting to reduce confusion and restlessness at
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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
Antidepressant medications for low mood and irritability
Anxiolytics for anxiety, restlessness, verbally disruptive
behavior and resistance
Antipsychotic medications for hallucinations, delusions,
aggression, hostility and uncooperativeness
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
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 persons view.
Say: May I help you? Do you have time to help me?
Youre safe here. Everything is under control. I apologize.
Im sorry that you are upset. I know its hard.
I will stay until you feel better.
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Helpful hints to
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 Alzheimers Association Clinical Issues and Interventions
Work Group, a team of consulting physicians and specialists,
developed the content of this page.
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