Key Points

The development of behavioral disturbances or neuropsychiatric symptoms (NPS) in dementia often precipitates early nursing-home placement and causes significant caregiver burden and distress.
Behavioral symptoms in dementia require evaluation of the specific symptoms, the patients comfort, the care environment, the needs of the caregiver, and the degree of distress of all those involved in the life of the older adult with dementia.
Delirium secondary to an underlying condition such as dehydration, urinary tract infection, medication toxicity, or pain is a common cause of abrupt behavioral disturbances in patients with dementia.
Pharmacologic treatment of behavioral disturbances in dementia is of limited efficacy and should be used only after environmental and nonpharmacologic techniques have been implemented.
No psychoactive medication prescribed to treat NPS of dementia should be continued indefinitely, and attempts at drug withdrawal should be made regularly (eg, every 3–6 months).
Increased mortality has been identified with the use of both first- and second-generation agents. All antipsychotic agents now carry an FDA warning regarding increased all-cause mortality in patients with dementia.
Despite these FDA warnings, antipsychotic medications may be needed for treatment of distressing delusions and hallucinations, and antidepressants may be helpful if symptoms of depression are evident. There is some evidence for considering mood stabilizers for symptoms such as impulsivity and aggression in patients who have significant behavioral disturbances.
When using any antipsychotic medication for any patient, and particularly when using them for an off-label indication, it is prudent to include in the informed consent process a mention of the possible association of treatment with increased mortality among patients with dementia, in addition to the other potential adverse effects, such as cerebrovascular events or metabolic syndrome. It is also advisable to document the process of informing the family member and, if capable, the patient of the future risk of mortality, stroke, and metabolic syndrome weighed against the present risk posed by the psychosis.
Treatment of psychiatric and behavioral disturbances in dementia is complex and may require several interventions as part of a comprehensive care plan. The goal is reduction rather than elimination of the distressing behavior. In refractory cases, a specialist, such as a geriatric psychiatrist, geriatrician, or neurologist with specific expertise in the pharmacologic treatment of the neuropsychiatric symptoms of Alzheimer’s disease, should be consulted.