What kind of person is apathetic
Diagnosis and therapy of behavioral disorders in dementia
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General therapeutic principles
Behavioral disorders are an integral part of dementia syndrome and amenable to therapeutic intervention (2). Nursing procedures are helpful in preventing delirium in dementia (18).
The therapy of behavioral disorders should be carried out in the overall therapeutic concept of coordinated non-drug and drug treatment approaches. In the first step, all persons involved are psychoeducated using a validating, resource-oriented approach (19). Then triggering factors and situations have to be recognized and avoided.
Psychiatric drugs should be used when the non-drug interventions have not been effective (2). A thorough somatic assessment must be carried out beforehand. The superficial question should not be “Which medication should the patient receive?”, But “What does he actually have?”.
Antidementia drugs (galantamine d = 0.14, p = 0.004; donepezil d = 0.07, p = 0.001; rivastigmine p = 0.002; memantine p = 0.004) and psychotropic drugs are effective in behavioral disorders (2, e11 – e16) (Table 1a and 1b).
First, an underlying somatic disease is treated with medication, such as a urinary tract infection with an antibiotic. The psychopharmacotherapy of the aggressiveness possibly resulting from the urinary tract infection is symptomatic and limited in time. Anticholinergic, sedating and muscle relaxing drugs should be avoided (20), as should drugs with a high interaction potential (PRISCUS list) (21) (Table 2).
Treatment of psychotic symptoms, increased psychomotor skills and aggressiveness: Neurolepsy is carried out using highly potent atypical neuroleptics if there are acute hazardous situations or severe psychotic symptoms. Slow dosing (“start low go slow”) over 1–2 weeks and short-term use due to cerebrovascular and cardiovascular risks (22) and increased mortality (23) must be taken into account. The drug of choice is risperidone (0.25 to a maximum of 2 mg / day; p = 0.002) (24). Olanzapine, quetiapine, and aripiprazole affect aggressiveness, but not delusional symptoms (e17, e18). Olanzapine has anticholinergic side effects (15).
Classic neuroleptics such as haloperidol (increased risk of extrapyramidal motor side effects) (25) or low-potency neuroleptics such as Melperon (sedation, risk of falling) should be used critically.
Clozapine and quetiapine are suitable neuroleptics for dementia with Lewy bodies without worsening Parkinson’s symptoms (26). Benzodiazepines should only be used for a short period of time. There is a potential for dependency, an increased risk of falling, and depression (27). If necessary, oxazepam or lorazepam, which do not increase their half-life with age, should be used. Carbamazepine acts on agitated and aggressive behavior (28), but also has a high potential for interaction. Valproic acid has no effects on agitated or aggressive behavior (29).
Treatment of affective symptoms and apathy: Serotin reuptake inhibitors have been studied best for treating affective symptoms (30). Hyponatremia with worsening cognitive deficits or delirium can occasionally occur. Fluoxetine and paroxetine (high interaction potential) or tricyclics (anticholinergic side effects) should be avoided (31). Citalopram has shown effectiveness (32). There are no randomized controlled studies on mirtazapine, escitalopram, venlafaxine (e19), reboxetine, and duloxetine. The use takes place as an individual healing attempt. Trazodone (33) and MAO inhibitors (34) show effectiveness in individual studies. Trazodone has a positive effect on anxiety (33). Risks are sedation, hypertonic derailment, and priapism. The treatment of apathy has not been adequately studied. However, the use of antidementia drugs as an individual attempt at healing can be helpful (e20).
Non-drug therapy methods
Evidence-based data are available on psychosocial interventions (2). Effect sizes for memory therapy (d = 0.47; [2, e21]), occupational therapy (d = 0.72; [2, e22]), physical activities (d = 0.68; [2, e23]) and active music therapy (d = 0.62; [e24]) were published.
First of all, all persons involved in the care of the patient must receive psychoeducation and training in order to avoid deficit-oriented treatment. Possible triggers of the behavioral disorders through the behavior of the caregiver must be reduced. When communicating with the patient, short, concise sentences, a flexible choice of words, and a sonorous, pleasant tone of voice are helpful (e25). The involvement of caring relatives is necessary.
Then the following specific methods of resource extraction are used:
Memory therapy: In weekly group sessions - for example by looking at older vacation photos, supplemented by conversations about times past - a pleasant world of emotions is activated, which strengthens the emotional part of the old memory and reduces restlessness or aggressiveness (e21).
Self-preservation therapy: By transferring an activity for which there is still sufficient competence, self-preservation therapy (19) promotes a recovery of self-esteem. The patient experiences himself perceived and used again. The prerequisite is the individual selection of the job based on the biography. The skills that are still preserved are practiced, those that have already been lost are avoided, since new content cannot be learned in the case of hippocampal atrophy. The effects are improved car-personal orientation and a reduction in behavioral disorders such as fear or aggressiveness (e26).
Occupational therapy (e22) and active music therapy: Activities such as singing together (p = 0.002; [e24]) affect behavioral disorders such as agitation (d = 0.75; [2, e22]) and irritability (d = 0.77 ; [2, e22]) if the choice of activity / music relates to the patient's biography and needs. In everyday clinical practice, painting and dancing are often helpful as non-verbal ways of expressing restlessness and agitation, despite the heterogeneous data situation (e27). The same applies to the use of a trained animal (e.g. dog therapy) to activate the patient.
Physical activity: Physical activation (going for a walk) and light physical training (physical exercise) can counteract depression (e23).
Snoezel therapy (e28): As a relaxation method that stimulates various senses (smell through aromatic oils [e29], touch through massage [e30]) in a room with pleasant light and sound effects, this method counteracts feelings such as insecurity and anxiety and reduces restlessness , Agitation, and aggressiveness (e28, e31).
Relative work: On the one hand, it includes knowledge transfer and exercises to avoid deficit-oriented procedures and promote resources, but on the other hand, it also includes measures to relieve the caregivers. This also includes family support to stabilize the home care situation (35). Relatives, in turn, can contribute therapy-relevant biographical aspects and often already have experience with specific behavioral disorders.
Psychotherapeutic interventions: They are useful for mild to moderate dementia (e32), but must be adapted to the patient's cognitive level and carried out in shorter, more frequent sessions. For example, with constant calling, which is caused by insecurity and loss of orientation, short and frequent frightening conversations can make the patient feel more secure again and the calling can be reduced.
Validation (36): This is a basic attitude when dealing with people with dementia. It is resource-oriented and excludes deficit-oriented procedures. First of all, one confirms the inner emotional world of the dementia patient, even if it appears unreal (for example the fear of an 83-year-old woman that she has given birth to a child and is unable to take care of it). This builds trust and security in the short term, which are needed to divert the patient from the stressful thoughts to another, pleasant topic using her short-term memory disorder. As a result, the emotional world is strengthened and behavioral disorders such as restlessness, fear and aggressiveness are reduced or prevented (37) (Table 3).
Behavioral disorders in dementia are common complications in the course of the disease. Particularly as the disease progresses, they are responsible for admission to a home, hospital treatment and the use of psychotropic drugs, and they are associated with a significantly higher amount of care. They are the greatest stressor for caregivers and caregivers. Behavioral disorders accompany dementia and often have understandable somatic and environmental causes that can be specifically treated. Diagnosis and differential diagnosis require an adequate somatic investigation, a differentiation from delirium and assignment to the type of dementia. It is necessary to collect a psychopathological finding and use specific scales.
Behavioral disorders are amenable to therapeutic interventions. An overall concept of non-drug and drug interventions should be drawn up. The drug treatment must not be based solely on the phenomenon of the behavioral disorder (e.g. aggressiveness), but must above all capture the underlying cause. Concomitant somatic diseases should be treated before using psychotropic drugs. The temporary use of psychotropic drugs makes sense if psychosocial interventions have not been effective, a pronounced delusional experience or dangerous situations exist. Anti-dementia treatment is evidence-based.
Non-drug therapy methods are becoming more important as more studies are available on their evidence. Memory therapy, occupational therapy, music therapy, and physical activity have proven their worth. Avoiding deficit-oriented procedures, promoting resources and working with relatives are helpful. Psychotherapeutic interventions are useful to a limited extent. Validation as a basic attitude with a strict focus on resources is necessary.
The global effect of non-drug therapy methods on behavioral disorders has been proven. Due to the heterogeneity of the interventions, some of which have different standards, the effect of specific procedures on specific behavioral disorders is limited. There is a need for further research here. It would be desirable to implement non-drug procedures more intensively in the daily practice of homes and hospitals. This could improve the quality of life of those affected and caregivers and avoid polypharmacy.
This work is due to my teachers Prof. Dr. Claus-Werner Wallesch,
Elzach (neurology) and Prof. Dr. Dedicated with gratitude to Albert Diefenbacher, Berlin (psychiatry and psychotherapy).
Conflict of interest
Prof. Kratz has received lecture fees from Lilly and Janssen-Cilag.
Taken in: November 13, 2016, revised version accepted: March 2, 2017
Prof. Dr. med. Torsten Kratz
Department of Psychiatry, Psychotherapy and Psychosomatics
Functional area of geriatric psychiatry
Queen Elisabeth Herzberge Hospital
How to quote
Kratz T: The diagnosis and treatment of behavioral disorders in dementia.
Dtsch Arztebl Int 2017; 114: 447-54. DOI: 10.3238 / arztebl.2017.0447
The German version of this article is available online:
Literature marked with "e":
www.aerzteblatt.de/lit2617 or via QR code
www.aerzteblatt.de/17m0447 or via QR code
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