The Assessment and Diagnosis of Alzheimer's Disease

Alzheimer's Disease

Alzheimer's disease, a disorder of pivotal importance to older adults, strikes 8 to 15 percent of people over the age of 65. Alzheimer's disease is one of the most feared mental disorders because of its gradual, yet relentless, attack on memory. Memory loss, however, is not the only impairment. Symptoms extend to other cognitive deficits in language, object recognition, and executive functioning. Behavioral symptoms, such as psychosis, agitation, depression, and wandering are common and impose tremendous strain on caregivers. Diagnosis is challenging because of the lack of biological markers, insidious onset, and need to exclude other causes of dementia.

Alzheimer's disease is the most prevalent form of dementia. However, many of the issues raised also pertain to other forms of dementia, such as multiinfarct (heart/circulatory related) dementia, dementia of Parkinson's disease, dementia of Huntington's disease, dementia of Pick's disease, frontal lobe dementia and others.

Mild Cognitive Impairment

Declines in cognitive (knowing, awareness, judgement) functioning have been identified both as part of the normal process of aging and as an indicator of Alzheimer’s disease. DSM-IV first designated this as "age-related cognitive decline" and, more recently, as "mild cognitive impairment" (MCI). MCI characterizes those individuals who have a memory problem but do not meet the generally accepted criteria for Alzheimer's disease such as those issued by the National Institute of Neurological and Communicative Disorders and Stroke—Alzheimer's Disease and Related Disorders Association or DSM-IV.

MCI is important because it is known that a certain percentage of patients will convert to Alzheimer's disease over a period of time (probably in the range of 15 to 20 percent per year). Thus, if such individuals could be identified reliably, treatments could be given that would delay or prevent the progression to diagnosed Alzheimer's disease. The evaluation of MCI spans the boundary between normal aging and Alzheimer's disease, and this topic is being evaluated in a number of research groups.

Behavioral Symptoms of Alzheimer's Disease

Alzheimer's disease is associated with a range of symptoms evident in cognition and other behaviors; these include, most notably, psychosis, depression, agitation, and wandering. Other behavioral symptoms of Alzheimer's disease include insomnia; incontinence; catastrophic verbal, emotional, or physical outbursts; sexual disorders; and weight loss. Behavioral symptoms, however, are not required for diagnosis. While behavioral symptoms have received less attention than cognitive symptoms, they have serious ramifications: patient and caregiver distress, premature institutionalization, and significant compromise of the quality of life of patients and their families. ' disease, especially behavioral symptoms, appears to place patients at risk for abuse by caregivers.

A Portrait of Alzheimer's

Counseling Alzheimer's patients and their families:

Alzheimer's disease can have devastating consequences for patients and their families. Counseling tailored to the manifestations of each stage of Alzheimer's disease is one approach clinicians can adopt to help meet patients' needs. In the early stage, treatment options and the development of advance directives should be the focus. Problems that arise with declining cognitive function, personality changes, and communication deficits should be addressed during the long second stage. During the final stage, the family will need support while they make the difficult decisions regarding end-of-life care.

Once considered a diagnosis of exclusion, Alzheimer's Disease (AD) is now considered a diagnosis of inclusion that can be accurately made in about 90% of cases, based on history and clinical presentation. Gradual onset and progressive cognitive decline are the hallmarks of the disease; motor and sensory functions are spared until the later stages.

Economic Impact to Seniors and Families

In addition to the emotional toll on families who watch their loved ones experience the drastic personality changes of AD, the economic impact of the disease is tremendous. The AARP states that AD costs the United States approximately $100 billion per year, including an estimated $36 billion in decreased caregiver productivity. Because of financial concerns, caregivers often try to keep the patient at home for as long as possible. Day care services for Alzheimer's patients typically begin at about $25 per day, and accommodations in a skilled nursing facility range in cost from $2,500 to $5,000 monthly.

AD is the leading cause of dementia, affecting an estimated four million Americans. Its prevalence has been predicted to double by the year 2050, or even by 2020. Most patients are diagnosed after age 60 and have an average life expectancy of eight to 10 years (but as long as 20) after onset of symptoms. Contrary to prior belief, recent studies show no significant difference in AD incidence between men and women.

Depending on the severity of the patient's impairment, caregivers may spend as many as 100 hours a week on patient-centered duties, often neglecting their own health and experiencing high levels of stress. Supportive services available to promote caregiver wellbeing are frequently underused. Patients and families often rely on lay literature and peers' advice for support. Thus, it is important for the primary care clinician to proactively become an additional resource for information and counseling.

AD progression is a continuum that may vary between patients. However, counseling for patients and their families may be most effective if it is based on three general disease stages.

DURING THE EARLY STAGE

The first (mild) stage of AD generally lasts two to four years. Among the signs and symptoms (which may be mistaken for manifestations of aging) are loss of recent memory, inability to retain new information, subtle personality changes (including abandonment of interests and activities, and increasing stubbornness), and difficulty communicating. Depression is common and may be the presenting symptom; first-time depression in a patient older than 65 should be investigated as possible dementia. Patients begin to lack judgment and insight.

After diagnosis, the patient and family need straightforward information about the disease and the cognitive and functional changes to expect with each stage. Patients should be discouraged from driving, as even mild cognitive deficits are associated with increased risk of accidents.

Families will benefit from a list of community resources. The Alzheimer's Association as well as the American Association of Retired Persons, for example, offers invaluable information about support groups, respite care, individual and family counseling, and other services that can help ease the caregiver's physical, emotional, and financial concerns. The National Institute on Aging funds nearly 30 hospital and university-based AD centers in the United States.

Patients and family caregivers also need information and advice about available medical treatments. Although medications approved to treat AD are expensive, their early use is an important means of prolonging the first stage -- and preserving the patient's ability to participate in creating an advance directive and making other important decisions. Effective early treatment may also make it possible to delay institutionalization.

Cholinesterase inhibitors have been shown to help maintain cognitive and global function and considerably slow disease progression in patients with mild to moderate impairment. This drug class includes donepezil, galantamine, and rivastigmine. The benefit of taking vitamin E or ginkgo biloba to slow the progression of AD is controversial. Nonsteroidal anti-inflammatory drugs (NSAID’s) and estrogen may confer protection against AD in long-term users, but they have not been shown to be effective treatments.

At each contact, patients should be evaluated for depression. Short-term treatment with selective serotonin reuptake inhibitors that have limited anticholinergic effects (eg, citalopram, sertraline) may be indicated for AD patients with depression. The family should be told to watch for and report symptoms such as apathy, irritability, refusal to eat, and weight loss, with the understanding that these may simply be symptoms of the dementia itself.

Caregivers should be reminded that attending to the patient's comorbid conditions can help slow the progression of disability and maintain function. Hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, arthritis, genitourinary conditions, and hypothyroidism are common concerns, as are vision and hearing impairment.

Additional Considerations

Early attention to the patient's environment is important (ie, consistency and structure, safety, moderate stimulation, and contrasting colors). Familiar items, including photographs and souvenirs, and orientation cues, such as clocks and calendars, can help stimulate memory and cognition. Some patients benefit from therapy using music, art, exercise, or pets, reminiscence therapy, and psychotherapy (emotion-oriented, supportive, and/or interpersonal).

The earliest stage of AD is an ideal time to broach the subject of advance care planning with the patient in the presence of the family or caregiver. More than one study has found that patients with early dementia can participate in completing advance directives. Considerations should include use of artificial nutrition and hydration, hospitalization, antibiotic use, and do-not-resuscitate orders.

THE MIDDLE STAGE

The moderate second stage of AD may last from two to 10 years. Patients require full-time supervision because of increasing confusion, declining ability to care for themselves, wandering tendencies, belligerence, and, for many, psychotic episodes. Communication skills continue to decline and delusions, agitation, and paranoia are common.

As symptoms progress, many caregivers begin to think about placing their loved ones in a long-term care facility. Behavioral strategies and appropriate pharmacologic management (discussed below) may help to delay this step. Families should be made aware of the available adult day care and community-based programs. They should also be directed to contact the AARP, the Alzheimer's Association or the appropriate constituent unit of the National Council on Aging (NCA) for information on financial resources.

Practical Coping Strategies

A safe, predictable environment and a consistent daily routine are the mainstay of managing potentially troublesome behaviors and the starting point for all other interventions. Safety measures include removing throw rugs and other obstructions over which patients may trip, and securing medicine, firearms, keys, toxic substances, and dangerous tools and utensils. Also, caregivers should be taught specific techniques to maintain optimal communication with the patient, such as those outlined by the Alzheimer's Association.

Apathy--manifested as loss of interest, poor persistence, blunted emotions, and lack of social interaction--may occur in 90% or more of AD patients. Apathetic patients may be mistaken as lazy or resistant, because they seem to expect others to initiate activities they themselves are still capable of performing. Functioning may be improved by regular exercise, increased social stimulation, prompt encouragement to begin activities, a structured activity routine, and use of visual cues to expected behaviors.

About 90% of patients also experience psychiatric manifestations, particularly behavioral disturbances. These include agitation (aggressiveness, combativeness, repetitious questioning, shouting, cursing, disinhibition) and wandering The caregiver should look for physical or environmental stressors--such as pain or discomfort, anxiety, lack of sleep, noise, clutter, and presence of large numbers of people--that may be triggering or exacerbating the behavior, and these should be removed wherever possible. Caregivers can calm the patient better with an easygoing attitude than by challenging him or her.

Spending time outside with the patient when the weather permits, incorporating exercise into the patient's daily routine, and limiting the patient's caffeine intake are ways caregivers can help the patient avoid sleeplessness. A regular sleep schedule should be maintained, with naps limited to 30 minutes and use of the bed restricted to sleep only.

Specific caregiving activities can be a common source of agitation. Bathing, which the patient may begin to find frightening and confusing, should occur when the patient is usually calmest. Urinary incontinence may be avoided by frequently scheduled or prompted visits to the bathroom. Patients should be encouraged to dress themselves, as long as they are able (with sufficient time allowed), and assisted if necessary. Clothing should be easy to put on and remove (eg, no zippers or buttons).

Wandering is a significant problem because it can be persistent and is inherently dangerous. Yet ambulation is considered an important factor in maintaining the AD patient's quality of life. One strategy is to provide a controlled environment where the patient may wander safely, rather than to try to eliminate the behavior. Wandering can be restricted by using child-proof doorknobs, mounting locks or latches higher or lower than eye level, obscuring doors with a scenic poster or curtains, and placing signs on doors with the words "stop" or "do not enter." Another effective technique is to keep outdoor clothing (symbols of departure) out of sight.

Motion detectors and remote door alarms may be helpful for caregivers. As a precaution, patients should always carry some kind of identification or wear an identification bracelet. At-risk patients should be registered with the Alzheimer's Association's Safe Return Program (www.alz.org/ResourceCenter/Programs/SafeReturn.htm).

Pharmacology

Additional drug therapy should be instituted only when behavior-modifying strategies become ineffective. The newer "atypical" antipsychotics (eg, risperidone, olanzapine, quetiapine) are preferable to traditional antipsychotics for the treatment of agitation in AD. Benzodiazepines, such as diazepam and alprazolam, have been used for infrequent agitation, but routine use is discouraged because of their potential adverse effects (including amnesia). Psychotropic medications should be initiated at low doses and gradually increased to achieve maximum efficacy with minimal adverse effects.

Occasionally, prescribing a short course of sleep medication for the AD patient will reduce nighttime awakenings, allowing the caregiver much-needed rest. Trazodone, zolpidem, and chloral hydrate are possible choices. (Info links to all drugs can be found on the AARP website).

The Option of Institutionalization

If the decision is made to place the patient in a long-term care facility, family members should receive full support; whatever choices meet the specific needs of the patient and others involved constitute the correct choice. The family should also be guided to choose a facility that provides services geared toward dementia patients, such as protected wandering areas, activities to enhance cognition, programs to maintain physical function, dementia care-certified staff members, and family education programs.

END-STAGE DISEASE

During the final stage of AD, which lasts one to three years, patients gradually lose motor skills (including ambulation and the ability to swallow), no longer recognize their families, cannot use or understand language, and become bedridden. Death usually results from secondary causes, often aspiration pneumonia; eating difficulties, immobility, and incontinence are risk factors for imminent death in late-stage AD.

Patients with severe dementia no longer appear to respond to therapy for cognitive impairment. Comorbid conditions should be treated conservatively to minimize short-term complications. Hospitalization for pneumonia is not advised because it may increase functional deterioration and the risk of death.

The most important area of concern for families is end-of-life care. If advance directives have not previously been put into place, families should be counseled to base decisions on what they believe the patient would want. Because the range of management choices is broad, family members may need encouragement to shoulder the responsibility of decision making. Although death is inevitable, the health care provider should help the family focus on preserving quality of life.

As life expectancy dwindles, active treatment becomes less effective and patients who do not understand such interventions may become increasingly resistant; often, too, they are unable to complain of adverse effects. Thus, optimal end-of-life care should be centered on providing maximum patient comfort rather than attempting to prolong life. Specifically, pain management and other palliative interventions are preferable to more aggressive treatment, such as feeding tubes, intravenous hydration, and artificial ventilation, which may only prolong the dying process. For further information on measures to manage the dying process, please contact the AARP or visit their website.

Treatment of Alzheimer's Disease

OVERVIEW

Ongoing regular medical management of general health (other medical conditions and prevention), in addition to monitoring of cognitive deficits, is essential. Management goals and activities should be based on a solid alliance with the patient and family and thorough psychiatric, neurological, and general medical evaluations of the nature and cause of cognitive deficits and associated non-cognitive symptoms (American Psychiatric Association, 1997). All evaluations must take into account the effect of cultural practices and beliefs on symptomatology and appropriate treatment options. Ongoing efforts should also include periodic monitoring (a minimum of every 6 months) of the development and evolution of cognitive and non-cognitive symptoms and their response to intervention (American Psychiatric Association, 1997). It is important for health care professionals to be sensitive to symptoms associated with AD to facilitate early intervention when unusual or sudden symptoms arise.

RECOMMENDATIONS

Develop and implement an ongoing treatment plan with defined goals. Include:

• Use of cholinesterase inhibitors, if clinically indicated, to treat cognitive decline (for physicians only)
• Appropriate treatment of medical conditions
• Referral to adult day services for appropriate structured activities such as exercise and recreation

Treat behavioral symptoms and mood disorders using:

• Non-pharmacologic approaches, such as environmental modification, task simplification, appropriate activities, etc.
• Referral to social service agencies or support organizations, including the Alzheimer's Association's Safe Return Program for people who may wander
• Medications, if clinically indicated and non-pharmacological approaches prove unsuccessful

DISCUSSION

Effective treatment of patients requires development and implementation of a plan with defined goals for the patient. Patient care goals should be developed in consultation with the patient (as capable) and with the patient's family. The treatment plan should include objectives that relate to the accomplishment of these goals. Patient goals should be developed using an individualized approach to the patient's needs, values, and preferences and may likely be modified as the disease progresses. Early discussions of future care options with the patient and family will provide guidance to the PCP in modifying patient care goals that are acceptable to patients with AD and their family members in time and place.

Treatment Plan: Referral to Community Based Services

The PCP is in a unique and important position to direct the AD patient and family to available resources that may assist in care provision and improve the quality of life of both the patient and caregiver. The "geriatric landscape", or sites where elders receive care, now includes congregate housing, assisted living, board and care, continuing care communities, senior hotels, foster care, group homes, adult day services, respite care, Programs for the All-Inclusive Care of the Elderly (PACE), retirement homes and communities. Due to the fragmentation of community-based long-term care services, PCP's may feel unprepared and find it challenging and time-consuming to fulfill this important role. For instance, moderate evidence suggests many PCPs underutilize social-model services that would offer benefits not only to the patient, but the caregiver as well. Culture and language issues play an important role in the use of community-based services, and PCPs must be sure to make referrals to services that are appropriate to cultural values and to organizations that can accommodate the needs of patients of different ethnic backgrounds (e.g. language). Referral to adult day services with staff that cannot communicate with the patient or family members may present a more confusing environment to the person with AD than other community-based services that provide staff members with the appropriate language skills. Several organizations, such as the American Association of Retired Persons, the Alzheimer' Association and the Caregiver Resource Centers offer help lines, direct services, support groups, information, advice, referral, and assessment. These organizations will provide information on local community-based services available to AD patients and caregivers.

Specialized services are available including adult day services, respite care, skilled nursing care provided by home health agencies; and outreach services as offered by Area Agencies on Aging and Councils on Aging. Empirical evidence also suggests that adult day services can substantially reduce levels of caregiver stress, improve psychological well being and provide needed structured environments for the patient that reduce behavioral symptoms. To date there have not been strong evidence-based studies on adult day services, however, expert opinion and Workgroup consensus suggests that while participation in adult day services does not appear to improve cognitive functioning, it can result in marked improvements in mood and/or behavior. Workgroup consensus also suggests that persons with dementia involved in activities like music therapy experience improved social/emotional skills, decreased behavioral symptoms, and aided in recall and recognition, reminiscence, which can promote interpersonal connections, exercise programs and/or walking. Exercise has been shown to be particularly important for maintaining mobility and may improve cognition. The rest and relief that caregivers experience as a result of adult day services, as well as the opportunity to do more things they enjoy, has been shown to have a significant association to an improved relationship with the affected individual.

Use of respite programs, such as adult day services, is an underutilized but appropriate strategy for caregivers whose social contacts have become impaired due to caregiver responsibilities. Sustained use of adult day services may also delay or decrease the likelihood of nursing home placement. Often families do not initiate and use these types of services on an ongoing basis until institutional placement is imminent. Earlier links with community services may be beneficial since it appears that families may only consider community service use well after the point of intervention could impact nursing home placement. This may explain why some research suggests that utilization of community-based services does not impact institutionalization.

Treatment Plan: Other Medical Conditions

Management of other medical conditions of the AD patient includes focus on prevention, in addition to routine monitoring. Since judgment and memory impairment are key features of AD, the PCP should expect under-reporting of symptoms and problems. The nature of cognitive impairment progression will often impact the patient's ability to manage other concurrent medical conditions (e.g. forgetting to take required medications). Regular surveillance and health maintenance visits should be scheduled at least every six months or more frequently based on the patients' health conditions.

The PCP should:

• Directly address security, safety and dependency needs
• Review treatment of existing co-morbid conditions, including review of administration and dosage of medications
• exercise program to maintain safe ambulation
• Evaluate acute changes
• Expect unreported problems (e.g. urinary tract infection).

Sensory Deficits

Visual and auditory deficits are common in older persons and may exacerbate symptoms of cognitive decline. The PCP should ensure that corrections (e.g. glasses, hearing aids) are optimal and used properly. Sensory deficits can affect patient performance on assessment/evaluation scales; therefore, it is important to distinguish if low scores are due to sensory deficits or due to actual cognitive decline.

Dental Care

Routine dental care is essential for the AD patient, and may be challenging to accomplish due to behavioral or mobility issues (American Dental Association, 1994). Available assessment instruments can determine the safety and behavioral symptoms that may be experienced with an AD patient during a dental visit. Specialists in geriatric dentistry are available for oral care of the AD patient. Dental providers can also recommend oral devices for use by caregivers of patients unable to continue their daily oral hygiene activities.

Treatment of Behavioral Symptoms and Mood Disorders

General Approach to Treatment:

Behavioral symptoms are often the most difficult aspect of care giving, and treatment of behavioral symptoms can help to delay institutionalization. The literature does not provide strong evidence-based research regarding the development of behavioral symptoms in each individual, however, expert opinion and Workgroup consensus suggest successful management of behavioral symptoms requires the PCP to develop early, appropriate and individualized care plans which must be evaluated regularly. Before initiating any kind of care plan to manage behavioral symptoms, it is imperative for the PCP to rule out any medical or medication-related causes of the behavioral symptoms. After ruling out these other factors, a behavioral assessment should be conducted and non-pharmacological interventions - the first approach to behavioral management - should include simplifying the environment and routines; distracting, rather than confronting, arguing or disagreeing; ensuring safety regarding wandering; and assisting the caregiver to understand the underlying cause of the behavior. In addition, strong evidence suggests the PCP should assess for identifiable causes of agitation, such as pain. In general, steps to managing challenging behaviors include identifying the behavior, understanding its cause, and adapting to remedy the situation.

Non-Pharmacologic Treatment Approaches

Non-pharmacologic interventions consist of a modification of the patient's environment and routine. Special attention should be paid to the triggers of the problem behavior to select effective interventions. The PCP should encourage the establishment of an exercise routine for the patient, to maintain ambulation and improve patient behavior and mood.

There is moderate to strong evidence that supports specific non-pharmacologic treatment suggestions for AD-related behavioral symptoms, including:

• Provide the patient with a structured, predictable routine (exercise, meals, and bedtime should be routine and punctual)
• Explain all procedures and activities in simple and straightforward terms to the patient before performing them
• Simplify tasks
• Allow patients to dress in their own clothing and maintain possessions
• Use calendars, clocks, labels, or newspapers for orientation to time
• Reduce excess stimulation and outings to crowded places (overexposure to environmental stimulation can lead to agitation and disorientation)
• Avoid glare from windows and mirrors, noise from TV, household clutter
• Provide a safe environment: no sharp-edged furniture, slippery floors and throw rugs, and obtrusive electric cords
• Equip doors and gates with safety locks
• Install grab bars by the toilet and in the shower
• Use lighting to reduce confusion and restlessness at night
• Use distraction and redirection of activities
• Provide music, especially during meals and bathing

Details from the AARP state that caregivers can be taught techniques for managing behavioral symptoms as well. One approach is the three R's: Repeat, Reassure, Redirect. Using this technique, caregivers can divert the attention of a person with AD from a problematic situation and provide a useful activity. Another approach for caregivers is the ABC's (Antecedent, Behavior, Consequences) of behavioral analysis. This technique provides insight into the precipitants (antecedents), behavioral interpretations (behavior) and inadvertent reinforcements (consequences) relevant to understanding and managing behavioral alterations. Using the ABC's, caregivers can avoid triggering behavioral symptoms and understand the context in which the AD patient's behavioral symptoms occur. Caregiver support groups sponsored by the AARP, the Alzheimer's Association or Caregiver Resource Centers are an excellent resource for caregivers to learn these and other management strategies.

Pharmacologic Intervention for Behavioral Symptoms

When non-pharmacological approaches fail to treat agitation or other behavioral symptoms, psychotropic medications can be effective in the management of some symptoms, but must be used with caution due to potential drug interactions and side effects. Utilize medications for specific target symptoms so that improvement or lack of improvement can be monitored. When prescribing pharmaceutical agents, side effects should be closely monitored.

Behavior-controlling drugs should be used cautiously and only for specified purposes. Physicians should take the extra time to explain possible benefits and side effects and establish criteria on which to base a decision for continuation. It is also recommended that clinicians begin with low doses.

The use of psychotropic medications has been shown to be very effective, but dementia patients are often more susceptible to severe side effects that necessitate close observation and frequent adjustments in dosage (American Psychiatric Association, 1997). There are several key factors that are influential in medication prescription. These include awareness of potential drug interactions and side effects (e.g. worsening of cognitive impairment, increased susceptibility to falls); always using low starting doses and small increases; and avoiding non-essential poly-pharmacy. Standard therapies should be used and any condition that could lead to deterioration of mental function should be treated aggressively to avoid aggravating the symptoms of AD. Strong evidence from two studies have noted that a person's response to medications, including psychotropic medications (e.g. neuroleptics, tricyclic antidepressants, etc.) can be affected by biological differences, eating behaviors and/or environmental conditions that affect drug metabolism and distribution in the body (pharmacokinetics), and the body's response to the drug (pharmacodyamics). The PCP should review the patient's history with the medication if taken before, or other responses to medications that might come from the same family as the psychotropic medication.

To summarize pharmacologic management of behavioral symptoms:

• Prior to initiating treatment with new medication, consider if the behavior may be caused or exacerbated by a current medication
• Delirium, pain or an acute medical condition (e.g. UTI, constipation, pneumonia) should be ruled out
• Use of classes of medications that have demonstrated effectiveness in managing problematic behaviors include antidepressants (low mood, irritability), anxiolytics (anxiety, restlessness, verbally disruptive behavior, resistance), antipsychotics (hallucinations, delusions, agitation), and anticonvulsant mood- stabilizers (hostility, agitation, uncooperativeness)
• Systematic trials of single agents should be tried rather than the use of multiple agents
• Start with low doses and increase gradually until a therapeutic effect is achieved
• Periodically reduce psychopharmacologic agents after behavioral symptoms have been controlled for 4 to 6 months to determine if continuing pharmacotherapy is required.

Common Forms of AD-related Behavioral Symptoms and Treatment Recommendations

Wandering

A main role of the PCP is to advise families of the danger of wandering and provide referrals to community agencies, such as the Alzheimer's Association, that can assist. In terms of decreasing the hazard, patients who wander should wear identification at all times, be provided an unrestricted place to wander, such as a fenced backyard, and daily exercise, such as walking. An in-house alarm or chimes to prevent unsupervised wandering should be considered, and complex door locks, or safety gates can be installed. Those activities or behaviors that decrease wandering such as TV, movies, or music should be identified and utilized. The Alzheimer's Association Safe Return program can help identify, locate, and return wandering or lost patients who have been registered with them.

Pharmacologic treatment is ordinarily not appropriate for nonaggressive behaviors such as wandering, and drugs should only be used when all non-pharmacologic interventions have proven unsuccessful. If it becomes necessary, drug choices include antipsychotics, minor tranquilizers, and antidepressants.

Depression

The treatment of depression in an AD patient is extremely important, given that strong evidence suggests that concurrent depression in AD patients has been associated with excess disability, increased caregiver burden and greater mortality. There is strong evidence supporting the use of antidepressants. With depressed patients with AD, selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, paroxetine, fluvoxamine, sertraline, and citalopram) appear to be the best medications to use due to their better tolerability. If a patient has no response to SSRIs, or adverse side effects with them, the PCP should switch to tricyclic antidepressants. The secondary amines with less anticholinergic effects (nortripyline and desipramine) should be used. Physicians may wish to familiarize themselves with a small number of antidepressants, use them consistently to become clinically experienced with them, and follow the dictum "start low, go slow" in order to avoid potential side effects. The medications most useful in depression superimposed on AD are those with minimal anticholinergic side effects. It is often unclear when treating depression in the demented elderly whether the PCP is treating depression as a symptom or as a major or minor depressive episode, and the selection of the appropriate medication must be based on the patient's clinical presentation and the side effect profiles of the medication.

Agitation

There is agreement that agitated behavior is a multidimensional, complex concept in terms of assessment and intervention. Categories of interventions include modifying the environment, interpersonal strategies, and use of physical or chemical restraints. However, the use of restraints is not recommended. In terms of medication, anxiety and agitation that cannot be handled by gentle reassurance may respond to short-acting anxiolytics, such as alprazolam or lorazepam.

Sleep Disorders

Sleep disturbances are common and pharmacologic intervention should be considered only when other non-pharmacologic interventions have failed (American Psychiatric Association, 1997). The sleeping area should be free of distractions and might contain nightlights if helpful to the patient. Caregivers should be instructed to try to limit the amount of sleep during the day. Naps should be kept short and there should be increased exercise or activity in the morning/early afternoon. Patient should be dressed during daytime hours. Caffeine and nicotine should be avoided and nighttime fluids and diuretics should be restricted. Warm milk and tryptophan before sleep may be successful, as may a tepid bath or light snack high in carbohydrates. Pharmacologic treatment of other sleep disorders must take into account whether depressive symptoms, fear, pain, or side effects from other drugs underlie the insomnia. Great caution must be exercised and caregivers warned because of reactions (incontinence, instability/falls, agitation) with major tranquilizers. Antidepressants (e.g. Trazadone), minor tranquilizers or benzodiazepines may suffice in intermittent short-term doses, but should be terminated at the earliest possible time. Use of various dopamine agonists has been described in case reports, but the efficacy of these drugs has not been demonstrated in controlled studies. Simple remedies, such as use of melatonin, may help insomnia. For stronger sedation, a low dose of antipsychotic is preferable to a longer-acting benzodiazepine, which often has lingering effects. Diphenhydramine hydrochloride (over-the-counter) should be avoided because it may increase confusion due to its anticholinergic effects.

Schizophrenia in Late Life

Although schizophrenia is commonly thought of as an illness of young adulthood, it can both extend into and first appear in later life. Diagnostic criteria for schizophrenia are the same across the life span, and DSM-IV places no restrictions on age of onset for a diagnosis to be made. Symptoms include delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, as well as affective flattening, alogia or avolition. Symptoms must cause significant social or occupational dysfunction, must not be accompanied by prominent mood symptoms, and must not be uniquely associated with substance use.

Prevalence and Cost

One-year prevalence of schizophrenia among those 65 years or older is reportedly only around 0.6 percent, about one-half the 1-year prevalence of the 1.3 percent that is estimated for the population aged 18 to 54.

Higher Total Cost and Misuse of Prescription and Over-the-Counter Medications

According to the AARP, older persons of retirement age use prescription drugs approximately three times as frequently as the general population and the use of over-the-counter medications by this group is even more extensive. Annual estimated expenditures on prescription drugs by older adults in the United States are $15 billion annually, a fourfold greater per capita expenditure on medications compared with that of younger individuals. And, not surprisingly, substance abuse problems in older adults frequently may result from greater use and misuse, that is, under use, overuse, or erratic use of such medications; such patterns of use may be due partly to difficulties older individuals have with following and reading prescriptions. In its extreme form, such misuse of drugs may become drug abuse.