ABSTRACT
Psychotic symptoms and disruptive behavior frequently complicate the course of Alzheimer’s disease (AD). Between 70% and 80% of patients with dementia display agitated behavior;1 however, the United States Food and Drug Administration (FDA) does not specify agitation in AD as an indication for treatment with antipsychotic medication.2 The entity ‘behavioral and psychological symptoms of dementia (BPSD)’ is considered too broad and non-specific to serve as a target for medication. Instead, Jeste and Finkel have proposed that ‘psychosis of AD’ be recognized as a distinct syndrome.3 In a recent study of 329 patients with AD, Paulsen et al found the cumulative 3-year incidence of psychosis to be 50%.4 Putative risk factors for the development of psychosis of AD include extrapyramidal signs (EPS) such as parkinsonian gait and bradyphrenia, as well as accelerated cognitive decline.4,5 Although symptoms may appear at various stages of dementia, longitudinal studies indicate that once present, psychosis tends to persist or recur over several years.6-9 Psychosis is often associated with agitated behavior in AD. Together, these symptoms comprise important predictors of caregiver distress and early institutionalization of patients, and thereby impose a substantial financial burden on society.10-13
Non-pharmacological approaches can be effective first-line treatments for behavioral disturbances in dementia.14,15 Only when symptoms begin to compromise the safety and/or quality of life of patients or caregivers are pharmacological interventions indicated.16 Antipsychotics have been the most widely used and extensively studied class of medications for the treatment of behavioral complications of dementia.17 Although they have been shown to provide some therapeutic benefit, their use remains complicated by side-effects. The newer, atypical antipsychotic medications are better tolerated than the conventional ‘neuroleptic’ agents; however, studies indicate that they are not without limitations in vulnerable elderly patients.
