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Review Article

Psychiatric Aspects
Address correspondence to
Dr Chiadi U. Onyike, Johns
Hopkins University, 600 N
Wolfe St, Meyer 279, Baltimore,
MD 21287, conyike1@jhmi.edu.
Relationship Disclosure:
Dr Onyike has received
of Dementia
personal compensation as Chiadi U. Onyike, MD, MHS
special issue editor for the
International Review of
Psychiatry and the Psychiatric
Clinics of North America and ABSTRACT
has given expert legal
testimony for the Paley Rothman Purpose of Review: The psychiatric aspects of dementia are increasingly recognized
law firm on disabilities related as significant contributors to distress, disability, and care burden, and, thus, are of
to frontotemporal dementia. increasing interest to practicing neurologists. This article examines how psychiatric
Dr Onyike receives research
funding from the Jane Tanger disorders are entwined with dementia and describes the predictive, diagnostic, and
Black Fund for Young-Onset therapeutic implications of the psychiatric symptoms of dementia.
Dementia Research, the Recent Findings: Psychiatric disorders, particularly depression and schizophrenia,
National Institute of Neurological
Disorders and Stroke, the are associated with higher risk for late-life dementia. Psychiatric phenomena also
National Institute on Aging, the define phenotypes such as frontotemporal dementia and dementia with Lewy bodies,
National Institutes of Health, cause distress, and amplify dementia-related disabilities. Management requires a
the Robert and Nancy Hall
family, and Tau Therapeutics. multidisciplinary team, a problem-solving stance, programs of care, and pharmacologic
Unlabeled Use of management. Recent innovations include model programs that provide structured
Products/Investigational problem-solving interventions and tailored in-home care.
Use Disclosure:
Dr Onyike discusses the
Summary: There is new appreciation of the complexity of the relationship between
unlabeled/investigational psychiatric disorders and dementia as well as the significance of this relationship for
indications and evidence for treatment, community services, and research.
efficacy and risks of
prescribing antidepressants,
antipsychotics, and other Continuum (Minneap Minn) 2016;22(2):600–614.
psychotropic agents for
treating psychiatric aspects of
dementia, as well as the
alternatives to making these INTRODUCTION and their predictive, diagnostic, and
prescriptions, which include
behavioral interventions, The coincidence of primary (ie, neuro- treatment implications.
care programs, caregiver
support and training, degenerative) dementia and psychiatric LINKS BETWEEN PSYCHIATRIC
environment modulation, and disorders is increasingly seen as a com- DISORDERS AND DEMENTIA
structured recreation.
mon occurrence and as a significant con- The earliest descriptions of the primary
* 2016 American Academy
of Neurology. tributor to distress, handicap, care needs, dementias included psychiatric distur-
and health costs. Psychiatric disorders bances alongside the cognitive and
have long been viewed as epiphenom- functional symptoms. Alois Alzheimer
ena that complicate dementias that are identified anxiety, hallucinations, delu-
‘‘essentially’’ cognitive disorders, but sions, and agitation amid confusion and
contemporary views suggest: (1) some dense impairments of memory, orienta-
psychiatric disorders are integral to the tion, and knowledge that would define
dementia phenotype, (2) dementia the illness named for him.1 His con-
may be foreshadowed by syndromes temporaries, Arnold Pick, Paul Sérieux,
such as major depression and schizo- and Joseph Dejerine, described mid-
phrenia and states such as apathy and life deterioration of conduct and lan-
irritability, and (3) many psychiatric guage, which are the first descriptions
disorders complicate the course of the of frontotemporal dementia (FTD).2Y4
dementia by amplifying or adding to From these beginnings, primary de-
distress and disability. This article mentias came to be viewed narrowly
examines the overlap between psychi- as cognitive disorders, but in the past
atric disorders and primary dementias 35 years, observations of the ubiquity

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KEY POINTS
of psychiatric disorders in dementia although late-life variants of depression, h The majority of
and that patients experience one or anxiety, mania, and psychosis are rec- patients with dementia
more disturbances of mood, behavior, ognized. In contrast, primary demen- experience one or more
perception, and thought content have tias are generally conditions of midlife disturbances of mood,
been replicated numerous times.5Y9 and late life, although youth and young- behavior, perception,
Psychiatric symptoms in neurode- adult presentations occur. Psychiatric and thought content.
generative disease can arise from the disorders preceding cognitive dysfunc- h While most psychiatric
dementia phenotype, or from psychiat- tion and dementia have long been rec- states manifest as
ric disorders or psychological vulnerabil- ognized in schizophrenia, since Emil episodes, apathy
ity preceding the dementia. Additional Kraepelin described dementia praecox associated with
risk factors for development of psychi- as a chronic disintegration of cognition dementia is usually a
atric symptoms in neurodegenerative and conduct beginning in youth.18,19 persistent state.
disease include a family history of psy- Schizophrenia is now viewed as a het- h Primary psychiatric
chiatric illness, uncontrolled pain, and erogenous psychosis in which cognitive disorders usually
systemic illnesses that give rise to de- develop in youth and
dysfunction is common, and progres-
lirium. Nearly all community-dwelling early adulthood,
sive cognitive decline and dementia
elderly individuals with dementia will although first episodes
develop psychiatric symptoms within rare. Schizophrenia is believed to arise
from aberrant neurodevelopment, of depression, anxiety,
5 years, which commonly includes mania, and psychosis in
apathy, depression, anxiety, and, often, with deficiencies in dopamine and
midlife and in the
combinations of these and other symp- glutamate neurotransmission culmi-
elderly are recognized.
toms.10Y15 Predementia states such as nating in the disintegration of mental
function in early adulthood. Most cases h A subset of individuals
mild cognitive impairment (MCI) fea- with schizophrenia
ture psychiatric disorders, but less com- of schizophrenia feature static deficits
develop dementia in
monly than dementia.12,16 While most in attention, executive functions, and
later life, decades after
psychiatric states manifest as episodes, social reasoning from the outset, along- the onset of the
apathy associated with dementia is usu- side the illness-defining hallucinations psychotic state.
ally a persistent state,17 and its fre- and delusions. These cognitive disabil-
quency and severity increases along ities undermine treatment adherence
the continuum from prodrome (such and psychosocial adjustment.
as MCI) to advanced dementia.16,17 Only a minority of patients with
Psychosis in dementia sometimes per- schizophrenia develop dementia in
sists, especially in the phenotypes it later life (ie, decades after the onset
defines such as dementia with Lewy of the psychotic state).20 These patients
bodies (DLB).15 Some psychiatric dis- have dense impairments of memory
orders are wont to appear early in the
and executive functions, with relative
illness (such as apathy, anxiety, de-
sparing of language and visuospatial
pression, and irritability), whereas
other symptoms such as hallucina- functions.21 A recent 18-year observa-
tions, delusions, roaming, and abnor- tional study of a large Danish schizo-
mal feeding tend to appear later. As a phrenia cohort showed a greater than
general observation, psychiatric states twofold higher risk for dementia than
are more common in dementia clinics in the general population.22 The risk
and residential care settings than they was higher in midlife than in late life,
are in the community. an observation not easily explained by
Alzheimer disease (AD), where a
PSYCHIATRIC DISORDERS higher frequency in older members of
FORESHADOW COGNITIVE the cohort is expected. Neuropath-
DECLINE AND DEMENTIA ologic studies of cohorts and large se-
Primary psychiatric disorders usually ries have observed lower brain weight
develop in youth and early adulthood, in subjects who had schizophrenia
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Psychiatric Aspects of Dementia

KEY POINT
h Depressive symptoms and dementia, compared to those who polar disorder.30,31 Whether the risk
have been associated had schizophrenia and no dementia.23 for dementia is greater for young-onset
with cognitive decline A more recent analysis showed that versus late-onset depression is still un-
and transitions to neuritic plaques and neurofibrillary settled as studies have yielded mixed
dementia in individuals tangles that did not meet the threshold results.30,32 Recent data from a Swedish
with mild cognitive for a formal AD diagnosis showed a cohort of military conscripts suggests
impairment and other positive correlation with dementia se- that depression in youth is associated
mild cognitive disorders. verity.24 Thus, dementia in schizophre- with a nearly twofold higher risk for
nia appears to be related primarily to young-onset dementia, 33 although
insidious brain atrophy and, for some, this finding has not been replicated.
a consequent lowering of the thresh- Whereas a causal relationship between
old for coincident neurodegeneration major depression and dementia has
to cause dementia. not been established, depressive symp-
It may be that some cases of schizo- toms may appear in the dementia
phrenia, a schizophreniform state, or prodrome (Case 11-1). Furthermore,
other psychotic presentations, are pro- depressive symptoms have been as-
dromes of a dementia. One study of sociated with cognitive decline and
progranulin (GRN) mutation carriers transitions to dementia in individuals
describes a family in which two sib- with MCI and other mild cognitive
lings manifested a classic schizophre- disorders (ie, states of cognitive dys-
nia phenotype and a third sibling had function that do not reach a thresh-
a typical FTD.25 It is also now increas- old for dementia, or match formal
ingly recognized that up to 20% of definitions for MCI). Psychiatric dis-
carriers of the C9ORF72 mutation orders are more frequently observed
associated with FTD and amyotrophic in elderly patients with MCI and other
lateral sclerosis experience psycho- mild cognitive disorders than in their
sis,26Y28 although it is still uncertain age-matched peers with normal cog-
what proportion present with primary nition, and these associations have
psychosis. Earlier clinicopathologic been linked to worse cognition and
analysis of a brain bank cohort has functional disabilities.16,34,35 Studies
suggested that schizophreniform and of community-based elderly indi-
other psychiatric presentations are viduals have shown associations
more likely in patients with FTD who between depression, apathy, and
are younger than 45 years of age, irritability/agitation, and transitions
whereas later-life presentations are from normal cognition to MCI, and
more likely to feature impairments of from MCI to dementia.36Y40 A recent
cognition and social conduct.29 meta-analysis reached the same con-
Cognitive dysfunction has been ob- clusions, showing that transitions
served in cases of remitted major from mild cognitive disorders to
depression and bipolar disorder, par- dementia are predicted by depres-
ticularly affecting attention, executive sion (in community samples) and
function, and memory, and depression apathy (in the clinic).41
appears to be associated with increased
risk for late-life dementia.30 The risk for PSYCHIATRIC PHENOMENA
dementia appears to be higher in in- AS DEFINING FEATURES
dividuals with more severe depressive OF DEMENTIA
symptoms and appears to be associated Although dementia syndromes are
with the frequency of admission to psy- widely viewed essentially as cognitive
chiatric wards for depression and bi- disorders, many of these are defined by
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KEY POINT

Case 11-1 h Alzheimer disease


typically presents a
A 58-year-old man, who had formerly worked as a business manager,
variety of psychiatric
developed a severe major depression with anorexia and severe weight loss
symptoms, most
10 years prior to his presentation at the neuropsychiatry clinic. He did
commonly apathy,
not recover fully despite antidepressant therapy and, 3 years into his illness,
depression, anxiety,
developed irritability, religious passions, confusion, indecisiveness, and,
irritability, agitation,
intermittently, suicidal thoughts. Five years into the illness, symptoms emerged
and delusions.
of inattention, disorganization, and misreading of social cues. He became
talkative, loud, self-centered, and compulsive. In the last year, symptoms
included low mental acuity, inattention, lack of spontaneity, indifference,
inertia, inflexibility, literalness, rigid moralizing, slovenliness, jocularity,
irritability, impulsiveness, restlessness, and overeating. His behavior had
engendered conflict in his marriage and in his community. A neuropsychological
assessment ordered by his psychiatrist and performed in the month before
the current visit showed impairments in attention, executive functions, and
emotion recognition. He had no other significant past medical history, and
his current medications included paroxetine and lamotrigine. In the clinic, the
mental status examination showed paucity of thought, indifference, and
shallow affect. He did not have depressed mood, suicidal thoughts, anxiety,
paranoia, or hallucinations. Compulsive behavior was not observed.
Neurologic examination showed normal cranial nerve, motor, sensory, and
coordination testing. Upper and lower extremity reflexes, including
plantar responses, were normal. He did not have primitive reflexes. Brain
MRI showed mild bilateral orbitofrontal atrophy, and fluorodeoxyglucose
positron emission tomography (FDG-PET) imaging showed low uptake in
the left cerebral hemisphere that was worse in the left frontal lobe.
Comment. This case illustrates a psychiatric syndrome as the initial
presentation of a primary dementia: behavioral variant of frontotemporal
dementia. The case demonstrates the diagnostic misdirection, dysfunction,
and disability that psychiatric states can produce and shows the types of
diagnostic data that reveal the neurodegenerative origin of the illness. The
reader is also reminded that primitive reflexes are not reliable indicators
of frontal lobe dysfunction, as they may be absent in the early stages of
frontotemporal dementia.

psychiatric phenomena. AD presents a delusions, anxiety, and depression. Rapid


variety of these states, most commonly eye movement (REM) sleep behavior
apathy, depression, anxiety, irritability, disorder is also characteristic of these
agitation, and delusions. Hallucina- conditions42 and has been associated,
tions and mania are uncommon in AD.14 albeit less frequently, with progressive
Vascular dementia also presents many supranuclear palsy, corticobasal de-
of the same symptoms, but especially generation, FTD with parkinsonism that
apathy, depression, anxiety, and irrita- is caused by mutations in the gene for
bility. On the other hand, patients who microtubule-associated protein tau
have DLB or Parkinson disease de- (MAPT), and some forms of spinocer-
mentia (PDD) often experience visual ebellar ataxia. In these conditions, the
illusions, pareidolia (perception of REM sleep behavior disorder may be
ambiguous visual forms as meaningful the earliest symptom, constituting a
objects) and hallucinations, paranoia, prodrome that precedes the motor

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Psychiatric Aspects of Dementia

KEY POINTS
h Cognitive deficits and syndrome or dementia syndrome by ered a rarity in FTD, was common in a
behavioral symptoms many years. Huntington disease fea- recently described neuropathology
are present in patients tures a triad of cognitive, affective, and cohort and may distinguish a subtype
with Huntington motor phenomena. The motor fea- of FTD caused by mutations in the
disease beginning tures, typically chorea, athetosis, tics, C9ORF72 gene, although the diagnos-
approximately 15 years bradykinesia, incoordination, and tic utility of this association has not
prior to motor diagnosis. ideomotor apraxias, are preceded by been examined. Visual illusions and
h The behavioral variant executive dysfunction, apathy, irri- hallucinations develop early in DLB
of frontotemporal tability, depression, and anxiety.43 and become florid, persistent, and,
dementia typically Such cognitive deficits and behavioral in many cases, associated with mis-
presents as a combination symptoms are present beginning identification, paranoia, delusions,
of socially offensive about 15 years prior to motor diag- and anxiety.26Y28,49 PDD manifests
behaviors, such as nosis.44 In asymptomatic Huntington illusions, hallucinations, paranoia,
indifference, impatience, disease mutation carriers, the earliest and delusions very late in the illness,
carelessness, insensitivity,
cognitive deficits are found in atten- usually many years after the de-
jocularity, intrusiveness,
tion, working memory, verbal learn- velopment of parkinsonism, subclini-
distractibility,
impulsiveness,
ing, verbal long-term memory, and cal cognitive dysfunction, anxiety, and
stereotyped behaviors, learning of random associations.45 depression. In PDD, visual hallucina-
compulsions, food Still, clinical diagnosis in Huntington tions, paranoia, and anxiety often
craving and gluttony, disease emphasizes the motor phe- arise as complications of dopaminer-
and slovenliness, and nomena and genetic testing; the gic therapy. REM sleep behavior dis-
many of these patients cognitive deficits and psychiatric order is a characteristic of DLB and
do not have noticeable phenomena lack the specificity for Parkinson disease that, when present
cognitive deficits until differential diagnosis but may facil- in advance of cognitive and motor
illness is established. itate early recognition in individu- dysfunction, facilitates the clinical
h Visual illusions and als who are known carriers of the diagnosis.42,50,51
hallucinations develop Huntington mutation or have a posi-
early in dementia with tive family history.46 IMPACTS OF PSYCHIATRIC
Lewy bodies and For some dementia syndromes, psy- DISORDERS ON DEMENTIA
become florid, persistent chiatric states are defining elements of Psychiatric disorders are frequently the
and, in many cases,
the illness and its diagnosis. Psychiatric main clinical focus because they bring
are associated
phenomena that define the dementia about distress directly and can exacer-
with misidentification,
paranoia, delusions,
syndrome are integrated into the diag- bate other morbidity. These states in-
and anxiety. nostic criteria for FTD and DLB, for crease the demands placed on relatives
example.47,48 To illustrate further, FTD and other caregivers and, thus, the
h Psychiatric symptoms in
is characterized by gross decline in levels of caregiver stress, and they also
dementia have been
linked to more severe
conduct (ie, the behavioral variant) or result in higher rates of resource utili-
cognitive and functional speech and language (the language zation.52 Psychiatric symptoms in de-
disabilities and faster variant). The behavioral variant of FTD mentia have also been linked to more
progression to severe typically presents as a combination of severe cognitive and functional disabil-
dementia and death. socially offensive behaviors, such as ities and faster progression to severe
indifference, impatience, carelessness, dementia and death.53,54 It has been
insensitivity, jocularity, intrusiveness, estimated, for example, that nearly
distractibility, impulsiveness, stereo- one-third of all dementia treatment
typed behaviors, compulsions, food costs are accounted for by psychiatric
craving and gluttony, and slovenliness, symptoms.55,56 These symptoms also
and many of these patients do not have shape the quality of life for many in-
noticeable cognitive deficits until illness dividuals with dementia. They are also
is established. Psychosis, once consid- major drivers of transfers to residential

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KEY POINTS
care, where they cause higher mor- & Documenting disabilities is vital h Patients with apathy
bidity and strain on caregivers.57Y60 for planning treatments and appear passive,
rehabilitation and for securing disinterested, and aloof,
PSYCHIATRIC SYMPTOMS AND public assistance, disability benefits, but do not experience
DIAGNOSTIC CONSIDERATIONS and other resources. a sad or depressed
The clinical history is the linchpin The mental status examination in- mood. In contrast,
of the diagnostic examination of pa- cludes not only detailed cognitive test- depression is associated
tients presenting with cognitive or with a sad mood, low
ing, but also a systematic examination
self-worth, feelings of
behavioral symptoms, and interview- of each psychiatric domain (eg, con-
guilt, and pessimism.
ing a source who has an intimate duct, mood, thought processes, per-
knowledge of the patient (usually a cepts). (For more information on the h Psychometric instruments
mental status examination, refer to the are used to provide
spouse, a close relative or friend, or a
measurements of the
longtime caregiver) is imperative. The article ‘‘The Mental Status Examination
psychiatric phenomena
goal of taking the patient’s clinical in Patients With Suspected Dementia’’
and their correlates
history is to capture all symptoms, de- by Murray Grossman, MD, FAAN, and
(particularly cognitive
scribe how the syndrome has devel- David J. Irwin, MD, in this issue of profiles and functional
oped over time, and make contrasts Continuum.61) The examination pro- disabilities) that facilitate
vides a characterization of the psychi- differential diagnosis,
between the current state and the
atric status of the patient and captures judgment of severity,
patient’s lifelong cognitive capacity,
symptoms of diagnostic value and in- and monitoring of
temperament, conduct, and habits.
forms the therapeutic approach. temporal change and
The following are key elements of Separating apathy from depression treatment responses.
the clinical history: at the bedside is valuable, as the former
& Interviewing the source privately is a signal characteristic of many de-
facilitates candor and disclosure. mentia phenotypes and is often mis-
This author typically asks the taken for depression. Patients with
patient’s permission to speak with apathy appear passive, disinterested,
their source. and aloof, but do not experience a sad
& Developing the chronology of or depressed mood. In contrast, de-
symptoms defines the syndrome and pression is associated with a sad mood,
the place of psychiatric symptoms low self-worth, feelings of guilt, and
within the context of the disease. pessimism. Apathy is best treated with
& Cataloging the symptoms and their structured behavioral routines and
severity defines the degree of psychostimulants, but some cases have
disability and distress. responded to bupropion (other anti-
& Identifying preceding or concurrent depressants are ineffective).
psychiatric states helps clarify Quantitative assessments of symp-
whether the patient has a primary toms can supplement the clinical ex-
psychiatric disorder. amination for differential diagnosis,
& Describing the context in which monitoring, and research. Psychomet-
current psychiatric states ric instruments are used to provide
emerged may point to modifiable measurements of the psychiatric
environmental, behavioral, or phenomena and their correlates (par-
social factors. ticularly cognitive profiles and func-
& Interrogating other physiologic tional disabilities) that facilitate
systems allows detection of differential diagnosis, judgment of
systemic derangements (such as severity, and monitoring of temporal
thyroid dysfunction) that may change and treatment responses. Psy-
mimic psychiatric disorders. chometric measurements are based
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Psychiatric Aspects of Dementia

KEY POINT
h A multidisciplinary team on self-reports, caregiver interviews, shadow the cognitive impairments; and
model involving or direct observations, and may be (3) syndromes defined by motor dys-
physicians, nursing, structured or semistructured. Since functions that usually overshadow
physical therapy, and self-reports are bedeviled by the loss cognitive and psychiatric phenomena,
other rehabilitative of self-monitoring and decisional ca- such as progressive supranuclear
services, as well as pacities in people with dementia, palsy and corticobasal degeneration.68
social work and measurements are usually sourced The alternative approach is to take
caregiver/family from caregiver interviews or direct a problem-solving stance, based on the
advocacy is often observations. Two classes of instru- understanding that some of the psy-
required for the optimal ments are used: standard psychiatric chiatric disturbances seen in demen-
management of
instruments adapted to dementia tia may be maladaptive reactions or
patients with psychiatric
practice and research objectives as patient-caregiver conflicts, rather than
disorders and dementia.
well as specially designed scales and symptoms of neurophysiologic distur-
questionnaires. The Neuropsychiatric bance. In this perspective, the psychiat-
Inventory (NPI),62 the most widely ric state is understood as arising from
used tool for measuring psychiat- the interplay of personal and environ-
ric phenomena in dementia, is a mental factors, implying that they can
semistructured screen-and-probe in- be extinguished or reshaped by behav-
terview of the patient’s spouse, care- ioral and environmental manipulations.
giver, or other source. It covers a
swarth of psychiatric states, and ver- PERSPECTIVES ON
sions have been developed for as- CLINICAL MANAGEMENT
sisted living and nursing home A multidisciplinary team model involv-
settings. The Neuropsychiatric Inven- ing physicians, nursing, physical ther-
tory Questionnaire (NPI-Q),63 a short apy, and other rehabilitative services,
version of the NPI, has found wide as well as social work and caregiver/
application in clinical practice and family advocacy is often required for
research. Numerous other tools for the optimal management of patients
measuring specific psychiatric phe- with psychiatric disorders and demen-
nomena in elderly individuals with tia. At the author’s institution, behavioral
dementia exist, such as the Geriatric care, case management, pharmacologic
Depression Scale and the Frontal Be- prescriptions, and physical, speech/
havioral Inventory for use in FTD.64Y67 language, and occupational therapy
At Johns Hopkins Hospital, we have are melded into an individualized treat-
described an algorithmic approach,68 in ment plan to relieve distress, provide
which the temporal clustering of cog- direction, promote adaptation, and
nitive, neuropsychiatric, and motor optimize quality of life.69 A healthy
symptoms and signs is used to define partnership with the patient and the
syndrome categories that facilitate dif- caregiver, and their education about
ferential diagnosis (Figure 11-1). The psychiatric symptoms, dementia, and
method classifies syndromes into: the interventions are vital for success.
(1) primarily cognitive syndromes, such The clinical formulation is the frame-
as the canonical (amnestic) AD phe- work for managing the psychiatric
notype and the primary progressive aspects of dementia. Where the for-
aphasias, in which the cognitive defi- mulation emphasizes specific disorders,
cits are the signal features; (2) predo- pharmacologic intervention specific to
minantly psychiatric syndromes such the underlying neurodegenerative dis-
as the behavioral variant of FTD and ease or psychiatric disorder may be in-
DLB, where psychiatric disorders over- dicated (ie, cholinesterase inhibitors for
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FIGURE 11-1 Algorithm for identifying the neurodegenerative types of dementia. The diagram shows how symptom clusters and
the syndromes they signify drive the differential diagnosis of dementia. Cognitive and motor syndromes define
pathways and, when complemented by psychiatric states (red text), may define specific dementia diagnoses
(such as the behavioral variant of frontotemporal dementia [bvFTD], frontotemporal dementia with amyotrophic lateral sclerosis
[FTD-ALS], and dementia with Lewy bodies [DLB]).
AD = Alzheimer disease; CJD = Creutzfeldt-Jakob disease; HD = Huntington disease; PCA = posterior cortical atrophy; PDD = Parkinson
disease dementia; PIA = progressive ideomotor apraxia; PLA = progressive logopenic aphasia; PNFA = progressive nonfluent
aphasia; PSP = progressive supranuclear palsy; SCA = spinocerebellar ataxia; SD = semantic dementia.
Reprinted with permission from Devineni B, Onyike CU, Psychiatr Clin North Am.68 www.sciencedirect.com/science/article/pii/S0193953X15000271. B 2015
Elsevier Inc.

AD or selective serotonin reuptake in- terventions directed at the environment, KEY POINT
hibitors [SSRIs] for depression). When their comfort, or the patient-caregiver h Where the clinical
problem solving is emphasized, psycho- relationship.70 The choice of approach formulation for
social approaches such as environment derives from careful analysis of the managing the psychiatric
aspects of dementia
remodeling, structured recreation, care- context of the psychiatric state. An-
emphasizes problem
giver education and training, and psy- other model views psychiatric states as
solving, psychosocial
chotherapy are more pertinent. One catastrophic reactions to frustration, approaches such as
commonly used psychosocial approach failure, or being thwarted, in which case, environment remodeling,
calls for formal analysis of the context simplifying tasks and providing direc- structured recreation,
and antecedents of the psychiatric state, tion and assistance can go a long way. caregiver education
so as to identify and remove (or man- Yet another approach is to examine the and training, and
age) precipitating factors. A patient patient-caregiver dyad for dysfunctional psychotherapy
who has exhibited agitated resistance interactions that will be corrected are pertinent.
of morning hygiene routines might through caregiver counseling and skill-
do much better when allowed to wake building training sessions. The efficacy
naturally or to eat first. The patient of structured skill-building programs
might also respond to nonspecific in- and tailored problem-solving methods

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Psychiatric Aspects of Dementia

KEY POINT
h Typical and atypical for dementia care has been demon- (Figure 11-2), which requires that the
antipsychotic agents strated in formal trials that examined problem be specified (describe) along
are associated with a effects on psychiatric disorders and with the contexts, triggers, and modi-
high risk for mortality caregiver coping.71Y74 fiers (investigate), that a collaboration is
in patients who Pharmacologic interventions for psy- undertaken with the caregiver to devise
have dementia. chiatric symptoms in dementia mirror a program of care (create), and that the
standard psychiatric practice, albeit implementation and results are moni-
with more cautious dosing, and they tored (evaluate).52 The DICE approach
remain in need of the validation of is now part of the Centers for Medicare
formal clinical trials.70,75,76 The na- and Medicaid Services toolkit of non-
tionwide Clinical Antipsychotic Trials pharmacologic programs for dementia
of Intervention Effectiveness did not care, which hopefully will stimulate
demonstrate efficacy for treatment of broad implementation, dissemination,
dementia-related psychosis, agitation, and evaluation. Another innovation is
and aggression, although a secondary the Maximizing Independence (MIND)
analysis suggested the atypical agents at Home study, which has used multi-
may have value, but that any bene- disciplinary teams for home-based case
fits might be offset by worsening of management that consists of individu-
cognitive disabilities, somnolence, par- alized care planning with monitoring,
kinsonism, weight gain, metabolic de- links to local services, dementia-related
rangements, and death.77,78 In DLB and education, and caregiver skills building,
PDD, quetiapine and clozapine are the which resulted in far fewer transfers
only antipsychotics recommended from home to residential care and
given the higher risk of extrapyramidal higher quality-of-life ratings than usual
side effects with other antipsychotic care in the pilot study.91 A larger
medications. Other antipsychotic drugs follow-up study, now underway, is aimed
must be avoided in these patients as at demonstrating the efficacy and scal-
they may precipitate life-threatening ability of this program.
rigidity and autonomic dysfunction. Pharmacologic interventions are still
The atypical antipsychotics are associ- indicated in some cases, owing to the
ated with mortality from cardiovascular biological grounding of some of the
and cerebrovascular events (and other psychiatric symptoms of dementia; vi-
causes of mortality, including infectious sual hallucinations in DLB, for example,
causes) in patients who have demen- cannot be formulated as arising from a
tia.79,80 The risk is higher still with the caregiver’s mishandling of a situation, a
conventional agents.81Y85 Where these patient’s misunderstanding, misinter-
agents are prescribed, risk can be pretation, or overreaction, or other so-
mitigated by routine use of planned cial mishap. Psychiatric states such as
discontinuation trials, in line with evi- these warrant pharmacologic interven-
dence that most psychiatric states in tion when they cause distress, are offen-
dementia do not persist longer than sive, or bring about significant morbidity
3 to 6 months and results from discon- (such as when depression causes an-
tinuation trials that show benefit.14,86Y90 orexia, weight loss, and malnutrition).
The development of structured be- Thus, present-day research continues
havioral programs that can be readily the search for physiologic indices of
disseminated are now underway, which psychiatric states in dementia, with the
will facilitate intervention in the home. hope that biomarkers will lead to more
One innovation is the Describe, Inves- effective case recognition and physio-
tigate, Create, Evaluate (DICE) method logic targets for drug development.
608 www.ContinuumJournal.com April 2016

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.


FIGURE 11-2 DICE (describe, investigate, create, and evaluate) approach to the examination, formulation, and management of
dementia-related behavioral problems. A two-part flow diagram is shown, illustrating the socially dynamic context of
the DICE approach (ie, the triad of patient, caregiver, and environment), the progression in its implementation, and the recursive
routines for managing high-acuity states. The bidirectional arrows in the triad emphasize the reciprocity of the dynamics that shape
many behavioral problems encountered in dementia care.
Modified with permission from Kales HC, et al, BMJ.70 www.bmj.com/content/350/bmj.h369. B 2015 British Medical Journal Publishing Group.

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Psychiatric Aspects of Dementia

CONCLUSION Neurol Psychiatr Springer-Verlag


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The author is supported by the Jane 2000;157(5):708Y714.

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and Stroke grants (R01NS056307 and disturbances in elderly people in the community:
findings from the first Nakayama study. J Neurol
1U54NS092089-01); the Robert and Neurosurg Psychiatry 2004;75(1):146Y148.
Nancy Hall family; and TRx 237-007
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