Psychiatric symptoms of dementia: Treatable, but no silver bullet

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In a systematic review, Sink et al 31 found citalopram (Celexa) to help reduce nondepressive agitation.

How long should depression be treated?

Antidepressant treatment is typically for 6 to 12 months. However, the optimal duration in an older adult with dementia is not known and is not addressed in either the American Psychiatric Association practice guideline on dementia 32 or the position statement of the American Association for Geriatric Psychiatry. 33

Patients with executive dysfunction, particularly those with perseveration and diminished inhibition, may be less likely to respond to antidepressants, and the symptoms are more likely to recur if they do respond. 34 It may be appropriate to treat them for a year and then withdraw the drug and monitor for recurrence. Some patients may need indefinite treatment.

No data on treating apathy

Apathy in elderly patients with dementia is common. It is found in nearly half of elderly patients with mild dementia and in nearly all of those with severe dementia. If accompanied by depressive symptoms such as sadness, guilt, feelings of worthlessness, passive or active death wish, changes in sleep or appetite, or tearfulness, apathy and other depressive symptoms may respond to antidepressive treatment—both behavioral and pharmacologic. When present in dementia without depressive symptomatology, apathy is unlikely to respond to antidepressants. In particular, SSRIs may actually induce or worsen apathy through their effect on the angular gyrus. Apathy can be very frustrating to family members but not troublesome at all to the patient.

No medication carries an indication for apathy in dementia. Although stimulants such as methylphenidate and modafinil (Provigil) have been used, there is no evidence to date from any controlled study of efficacy and safety in this population.

Try nondrug measures concomitantly

Given the limited evidence of efficacy of antidepressive therapy in demented elderly patients, nonpharmacologic therapy should be offered concomitantly.

Evidence-based nonpharmacologic treatment for depression in dementia includes increasing enjoyable activities and socialization with people and pets, reducing the need to perform frustrating activities, redirecting perseverative behaviors and speech, and addressing caregiver needs. 34 Exercise may improve physical functioning in depression with dementia. 35 A comprehensive sleep program may improve associated sleep disorders. 36

An intensive collaborative-care intervention 37 resulted in more demented elderly patients in the intervention group receiving a cholinesterase inhibitor and an antidepressive than in the usual-care group. Outcomes included fewer behavioral symptoms, less caregiver distress, and less caregiver depression.

So far, no randomized trial has shown electroconvulsive therapy to be effective in elderly patients with depression and dementia. 38


On the basis of small studies with some contradictory outcomes, 39 both older and newer anticonvulsants have been used in nonpsychotic agitation, aggression, and impulsivity in a variety of psychiatric disorders, brain injury, and dementia. 40 Most of the data are on the older drugs such as valproic acid and carbamazepine (Tegretol).

Valproic acid is associated with an adverse metabolic profile (hyperglycemia, weight gain, and hyperlipidemia), 41,42 dose-related orthostasis, sedation, and worsening cognitive performance. In addition, the possibility of thrombocytopenia and blood level fluctuations requires monitoring. Older adults may tolerate 250 to 500 mg/day with minimal adverse effects.

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