History

Fact Explanation
Fluctuating level of consciousness Amnesia refers to a specific deficit in new learning and memory. Amnestic disorders can occur in isolation,but in practice they are most commonly seen within the more global syndromes of delirium or dementia. A cardinal feature of delirium include fluctuating level of consciousness.[1].
Impaired attention and concentration Another cardinal feature of delirium.[1]. Delirium develops over a short period of time (hours to days) and fluctuates throughout the course of the day, characterized by a reduction in clarity of awareness, inability to focus, distractibility and change in cognition.[2].
Disorientation Delirium may develop acutely or sub acutely and is a medical emergency, often precipitated by potentially life threatening conditions.Disorientation one of that condition commonly associated with delirium.[1].
Frequent hallucinations and delusions. Another cardinal feature of delirium.[1].Late life dementias are associated with delusions and hallucinations.The most common delusions associated with dementing disorders were of people stealing, breaking in, or having intentions to persecute the patient or of food being poisoned.Visual hallucinations are the most common, followed by auditory hallucinations or combined auditory and visual hallucinations.The content of typical visual hallucinations includes persons from the past (such as deceased parents), intruders, animals, complex scenes, or inanimate objects.Delusions or hallucinations in Alzheimer's disease may be a marker of a more severe or rapidly progressive dementing process.[4].
Pain Pain is a significant trigger of behavioral disturbance in dementia patients.Most common complaints concern musculoskeletal pain such as joint, back, and leg pain. In dementia patients, cognitive impairment and communication issues lead to underreporting of pain incidence.[4].
Impairment of recent memory A cardinal feature of amnestic disorders. It Is due to deficits in the consolidation process involving passage of information from immediate memory to recent memory.[1].
Impairment of declarative memory Declarative memory pertains to facts about the world and past personal events that must be consciously retrieved to be remembered. Amnestic patients show an intact ability to acquire new skills at almost normal rates (procedural) but are unable to recall having engaged in the task before (declarative).[1].
Repetitive behaviours and wandering Seen in hyperactive delirium (30%). Patients are agitated and hyper alert with repetitive behaviors and wandering,[2]. Wandering/Pacing also seen in dementia.[4].
Anxious and restless Recognized feature in prodromal period of delirium.[2]. Anxiety also seen in dementia. There,anxiety is more prominent in the earlier phases of the illness and often results from anticipation of potentially stressful circumstances or an adjustment reaction to the increasing dependency associated with progressive functional decline.[4].
History of systemic disease or drug intoxication Delirium reflects brain dysfunction that is almost always due to identifiable systemic or cerebral disease or to drug intoxication or withdrawal states.[3].
Quiet and withdrawn Seen in hypoactive delirium (25%). Patients are quiet and withdrawn which is often missed on a busy medical ward.[2].
Language disturbance It is a well recognized feature of dementia.[2].
History of old age, terminal illness or surgery Delirium is common among elderly population.The point prevalence of delirium in the community is 1.1% among the general population aged over 55 years, and up to 14% in those over 85 years.Incidence of delirium is highest among certain subgroups including those with cancer, AIDS and terminal illness and after surgical procedures such as hip replacement and cardiac surgery.[2].
Cognitive impairment Well recognized feature among patients with dementia which have received the most attention in terms of targeted pharmacotherapy .[4]. Cognitive deficit is also a feature of delirium.[2].
Depression Major or minor depression is seen in up to one half of patients with the dementia. Unlike that of most behavioral symptoms, the frequency of depression does not necessarily increase with overall disease severity. Depression frequently goes unrecognized in patients with dementia because of the presence of behavioral disturbances and aggression as part of dementia.[4].
Sleep disturbances The normal changes in sleep that occur with aging (reduced REM and slow-wave sleep, with increased nighttime wakefulness and daytime napping) are exaggerated in dementia. The disruptions in night time sleep increase in magnitude with increasing severity of dementia. Decreased daytime activity may result from deficient physical stimulation or frailty and in turn cause sleep problems.[4].
Sexual Disinhibition It is a behavioral disturbance that seen among patients with dementia.Sexual symptoms such as exhibitionism and inappropriate touching (to self or others) need to be evaluated carefully.[4].
Apathy Apathy occurs as frequently as aggression or psychosis in dementia patients and is as important a source of caregiver distress. Apathy may best be characterized as a disturbance of motivation.Increased severity of apathy symptoms is associated with severity of cognitive impairment, the presence of psychotic symptoms, and with increased severity of symptoms of depression.[4].
Physical aggression Physical aggression also found to be associated with dementia itself.[4].
Self-Injurious Behavior Self-injurious behavior seen in patients with dementia.it may manifest as severe self-induced excoriations of the skin secondary to delusions of parasitosis or as excessive skin picking because patients feel “sand” and feel the sand moving through the body.[4].
Hoarding Hoarding, collecting a large number of unneeded objects,is commonly found in dementia. It can interfere with the hygienic management and health of patients.Patients with hoarding have been found to have a higher prevalence of repetitive behaviors, hyperphagia, and pilfering. Also, many nurses and physicians view hoarding as negative and assume that the patient is a bit “strange” or psychotic.[4].
References
  1. ERICKSON KR. Amnestic disorders. Pathophysiology and patterns of memory dysfunction. West J Med [online] 1990 Feb, 152(2):159-166 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002292
  2. WASS S, WEBSTER PJ, NAIR BR. Delirium in the Elderly: A Review Oman Med J [online] 2008 Jul, 23(3):150-157 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282320
  3. MARKOWITZ JD, NARASIMHAN M. Delirium and Antipsychotics: A Systematic Review of Epidemiology and Somatic Treatment Options Psychiatry (Edgmont) [online] , 5(10):29-36 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695757
  4. DESAI AK, GROSSBERG GT. Recognition and Management of Behavioral Disturbances in Dementia Prim Care Companion J Clin Psychiatry [online] 2001, 3(3):93-109 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181170

Examination

Fact Explanation
Dysarthria and Dysnomia Seen in pateints with delirium.[1].
Tachycardia and hepertention It is recognized in patients with delirium.It occurred due to autonomic dysfunction.[1].
Dysgraphia and Aphasia Seen in patients with delirium.[1]. Aphasia (language disturbances) also can seen in dementia. Patients with frontotemporal lobar degeneration (FTLD) suffer primarily from executive dysfunctioning and/or aphasia.[3].
Sweating and flushing Sweating and flushing occurred in delirium due to autonomic disturbances.[1].
Ataxia and Nystagmus Ataxia and Nystagmus also Reported in patients with delirium.[1].
Tremor/ Asterixis and Myoclonus Occurs in patients with delirium.[1].
Dilated pupils Dilated pupil is a manifestation of autonomic dysfunction. identified among delirium patients.[1].
Impaired visual acuity Impaired visual acuity may be associated with visual hallucinations in patients with Alzheimer's disease.[2].
Screaming Seen in dementia.Disruptive vocalization also tends to occur along with various other agitated behaviors.[2].
Agnosia In addition to memory impairment, the dementia syndrome includes at least one additional area of cognitive dysfunction, such as agnosias, dyspraxia, dysgraphia, dyscalculia. [4]. Agnosia means that failure to recognize or identify objects despite intact sensory function.[3].
Apraxia Impaired ability in carrying out motor activities despite the intact motor function. This is seen among patients with dementia.[3].However, occasionally, Amnestic Disorders may also present with agnosia, apraxia and aphasia being more prominent than memory deficits.[3].
References
  1. WASS S, WEBSTER PJ, NAIR BR. Delirium in the Elderly: A Review Oman Med J [online] 2008 Jul, 23(3):150-157 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282320
  2. DESAI AK, GROSSBERG GT. Recognition and Management of Behavioral Disturbances in Dementia Prim Care Companion J Clin Psychiatry [online] 2001, 3(3):93-109 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181170
  3. VAN DER FLIER WM, SCHELTENS P. Use of laboratory and imaging investigations in dementia J Neurol Neurosurg Psychiatry [online] 2005 Dec, 76(Suppl 5):v45-v52 [viewed 03 September 2014] Available from: doi:10.1136/jnnp.2005.082149
  4. ERICKSON KR. Amnestic disorders. Pathophysiology and patterns of memory dysfunction. West J Med [online] 1990 Feb, 152(2):159-166 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002292

Differential Diagnoses

Fact Explanation
Delirium Delirium is a common syndrome affecting many elderly patients. The syndrome of delirium can be defined as acute brain failure associated with autonomic dysfunction, motor dysfunction and homeostatic failure. It is complex and often multifactorial, and hence continues to be under diagnosed and poorly managed. Delirium develops over a short period of time (hours to days) and fluctuates throughout the course of the day. It is characterized by a reduction in clarity of awareness, inability to focus, distractibility and change in cognition.risk factors for delirium includes old age, surgery trauma sepsis ect.[1].
Dementia Dementia refers to a chronic-static or progressive impairment in intellect with a clear sensorium. In addition to memory impairment, the dementia syndrome includes at least one additional area of cognitive dysfunction, such as agnosias, dyspraxia, dysgraphia, dyscalculia, impaired abstraction, impaired judgment, expressive or receptive language deficits, or visuospatial perceptual difficulties.[2].
Alzheimer's disease This disorder affects 4% of persons older than 65 and reaches a 20% prevalence by age. The most frequent initial complaint is of impaired memory for recent information and events.The memory disorder of Alzheimer's disease is complex and varies with the stage. In the early stages, distinguishing it from age associated memory impairment can be difficult. Immediate (primary) memory is often normal in the early stages. As the dementia progresses, a more profound amnestic disorder sets in that is unaided by retrieval cues and includes deficits in immediate and remote memory in addition to the severe recent memory impairment.[2].
Transient global amnesia It may be due to transient ischemia in the posterior cerebral artery distribution.The condition occurs in middle aged or older patients of both sexes and is characterized by a suddenly impaired memory without associated neurologic findings. Recovery is complete within 24 hours, but during the episode the patient displays a profound anterograde and retrograde amnesia in a clear sensorium. Immediate memory is normal (repetition of verbal and nonverbal material is intact), but the patient may appear confused owing to the loss of secondary (recent) memory function, as recall for material after a several-minute delay is absent. The retrograde amnesia extends to events and memories anywhere from hours to years before the episode. After the episode resolves, permanent amnesia for the episode itself remains. [2].
Multiple sclerosis Memory is one of the most consistently impaired cognitive functions in patients with multiple sclerosis. Immediate (short-term) memory capacity as measured by digit span appears grossly intact, but retrieval of verbal information from secondary (long-term) memory is impaired, as measured on tests such as paired-associate word recall and logical memory for paragraphs. Patients with the chronic progressive form of multiple sclerosis may have relatively greater deficits in recognition tasks than other patients with multiple sclerosis, but even here the evidence points largely to an impairment of acquisition (registration) processes rather than to retention (consolidation) dysfunction.[2].
References
  1. WASS S, WEBSTER PJ, NAIR BR. Delirium in the Elderly: A Review Oman Med J [online] 2008 Jul, 23(3):150-157 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282320
  2. ERICKSON KR. Amnestic disorders. Pathophysiology and patterns of memory dysfunction. West J Med [online] 1990 Feb, 152(2):159-166 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002292

Investigations - for Diagnosis

Fact Explanation
Cognitive testing The MMSE (Mini-Mental State Examination) is the most widely used instrument to test cognitive function. Although it is used in the setting of delirium, it was not designed for this purpose. This may be effective in certain high-risk situations (i.e. post hip fracture) but further evaluation is needed. A drop of >2 points from baseline indicates delirium, whilst an improvement of 3 points or more indicates resolution. Confusion Assessment Method (CAM), is another screening tool specifically designed to detect delirium .This has reported sensitivity of >94%, specificity of >90% and is easy to use in a clinical setting. The third assessment tool is the Delirium Rating Scale (DRS). It covers a range of symptoms relating to delirium, not only useful for diagnostic purposes, but for assessing severity and distinguishing delirium from other disorders. Although accurate, it is more complex than the CAM, requires specialist trained Psychiatrists or Geriatricians and has mainly been used for research purposes until recently.[2].
CT In the recent practice parameter on the diagnosis of dementia, structural neuroimaging in the routine initial evaluation of patients with dementia is recommended as a guideline.The traditional view has been that computedtomography and magnetic resonance imaging (MRI) are performed to exclude other abnormalities.[1].
MRI Magnetic resonance imaging (MRI) are performed to exclude other abnormalities that are potentially amenable to surgical treatment, such as a tumour, haematoma, or hydrocephalus. Such potentially reversible conditions detected by imaging appear to underlie about 4% of dementias.It is increasingly being used in addition to exclusion of gross structural pathology, to addnegative or positive predictive value in the diagnosing the more common dementing illnesses.Hippocampal volume loss on MRI has been shown to predict subsequent fulfilment of neuropathological criteria of Alzheimer's disease (AD).A minority of patients with AD presents with prominent posterior cortical atrophy on MRI. Instead of that Vascular diseases are also observed on MRI[1].
Positron emission tomography (PET) The two main techniques that are used to study biochemical and physiological processes are positron emission tomography (PET) and single photon emission computed tomography (SPECT). PET shows glucose metabolism (using the metabolic tracer [18F] fluorodeoxyglucose or FDG). SPECT assesses changes in regional blood flow and oxygen metabolism. Both methods have reasonable to good discriminatory power in the comparison between AD and controls. Typically, temporal and parietal hypometabolism and hypoperfusion are observed in AD patients relative to controls. However, because the added value of PET and SPECT over clinical diagnosis and structural imaging is not always clear, these investigations are not considered essential in the initial diagnostic work-up of dementia.[1].
EEG Generalised slowing of the background rhythm on electroencephalography (EEG) is a frequent finding in AD and DLB,(dementia with Lewy bodies) and may be helpful in distinguishing such patients from those with depression. The described EEG changes are not specific for AD, and can also be found in other diffuse neuroencephalopathies. In FTLD (frontotemporal lobar degeneration), the EEG may be normal until a far advanced disease stage. EEG seems unable to distinguish MCI (mild cognitive impairment) patients from controls. However, it has been suggested that EEG abnormalities in AD are suggestive of a faster progression of disease.[1].
Genetic testing Only a small proportion of all individuals with dementia suffer from a familial form, caused by an autosomal dominant mutation. There are a few types of dementia that are uniquely autosomal dominantly inherited, such as Huntington’s disease and cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL). Genetic testing for these diseases in specialised centres results in high sensitivity and specificity.[1].
CSF fluid testing Cerebrospinal fluid (CSF) is in direct contact with the brain. CSF provides a ‘‘window to the brain’’ as biochemical changes resulting from pathological processes of the brain are reflected in it. Senile plaques and neurofibrillary tangles are the neuropathological hallmarks of AD.[1].
References
  1. VAN DER FLIER WM, SCHELTENS P. Use of laboratory and imaging investigations in dementia J Neurol Neurosurg Psychiatry [online] 2005 Dec, 76(Suppl 5):v45-v52 [viewed 03 September 2014] Available from: doi:10.1136/jnnp.2005.082149
  2. WASS S, WEBSTER PJ, NAIR BR. Delirium in the Elderly: A Review Oman Med J [online] 2008 Jul, 23(3):150-157 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282320

Investigations - Fitness for Management

Fact Explanation
Serum electrolytes Electrolyte disturbance (sodium, calcium, magnesium, phosphate) is a precipitating factor for delirium. So have to do a serum electrolytes test including calcium.[1].
Serum Creatinine and Serum glucose Carried out in patients with dementia. Useful in detecting renal failure and endocrine disturbance like diabetes which may predispose to delirium.[1].
Full blood count and blood culture Evaluation for infection is essential in the postoperative patient.In the older patient, occult infections present without the usual physiologic response of a younger adult such as fever and leukocytosis.Blood culture is performed to detect sepsis and bacteremia.[2].
Urine analysis It includes mid-stream urine for microscopy, culture and sensitivity.[1].It is useful in detecting urosepsis specially in postoperative patients.[2].
Chest X-ray Evaluation for infection is important in the postoperative patient as it may predispose to delirium.Pneumonia in post operative patients can be detected by using chest X ray.[2]..
References
  1. WASS S, WEBSTER PJ, NAIR BR. Delirium in the Elderly: A Review Oman Med J [online] 2008 Jul, 23(3):150-157 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282320
  2. ROBINSON TN, EISEMAN B. Postoperative delirium in the elderly: diagnosis and management Clin Interv Aging [online] 2008 Jun, 3(2):351-355 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546478

Investigations - Followup

Fact Explanation
Mini-Mental State Examination (MMSE) The Mini-Mental State Examination (MMSE) is another tool for assessing cognitive status.The MMSE measures orientation, attention, calculation, recall, and language, which allows both for screening cognitive dysfunction and following fluctuations over time. Other bedside tests to determine the presence of delirium include the executive clock drawing task, the Informant Questionnaire on Cognitive Decline in the Elderly and the Memorial Delirium Assessemnt Scale.[1].
References
  1. ROBINSON TN, EISEMAN B. Postoperative delirium in the elderly: diagnosis and management Clin Interv Aging [online] 2008 Jun, 3(2):351-355 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546478

Management - General Measures

Fact Explanation
Antipsychotics In delirium, antipsychotics are the drugs of choice and should be administered at the lowest adequate dosages. For more threatening agitation, a combination of antipsychotics and benzodiazepines along with ventilatory support has been utilized. Haloperidol, a typical antipsychotic, is the most frequently used and best studied antipsychotic medication for delirium due to its few anticholinergic side effects, few active metabolites, and small likelihood of causing sedation. Most studies have used doses of haloperidol from 0.25 to 0.50mg every four hours for the elderly or seriously medically compromised patients to doses of 2 to 3mg per day in healthier patients. For very agitated patients, bolus doses of 5 to 10mg per hour intravenously have been used in hospital settings.A study with haloperidol, chlorpromazine, and lorazepam groups have demonstrated improvements in the mental status as measured by the Delirium Rating Scale in the haloperidol and chlorpromazine groups but not the lorazepam groups.With the advent of atypical antipsychotics and their decreased risk of extrapyramidal side effects, there has been increased interest in using these agents for delirium.Numerous studies support the assertion that risperidone, olanzapine, and quetiapine have the best data for the treatment of delirium among the atypical antipsychotics.[1].
Cholinesterase Inhibitors The cholinergic deficiency contributes to the neuropsychiatric symptoms of Alzheimer's disease, and cholinomimetic therapies such as cholinesterase inhibitors ameliorate these neuropsychiatric symptoms. Neuropsychiatric inventory data from trials of several cholinesterase inhibitors (including rivastigmine, donepezil, galantamine, and tacrine) have suggested improvements in psychiatric and behavioral disturbances in Alzheimer's disease patients. Rivastigmine improves behavioral symptoms in patients with Alzheimer's disease and Lewy body disease. Cholinesterase inhibitors are increasingly being considered by many experts as first line for the treatment of mild-to-moderate behavioral disturbances in patients with Alzheimer's disease and related disorders.[2].
Benzodiazepines Benzodiazepines are routinely used to treat sleep problems and behavioral disturbances in dementia patients. Lorazepam used for nighttime sedation obviates the need for multiple benzodiazepine preparations.In elderly demented patients, benzodiazepines can cause side effects even at low therapeutic dosages that are not seen in nondemented elderly and younger patients.Best practice recommendations for benzodiazepine use in patients with dementia include (1) emergency or short-term (few days) use; (2) use of short half-life agents, preferably metabolized through phase 2 (e.g., lorazepam, oxazepam); and (3) avoidance of other central nervous system depressants.[2].
Interact with the patient in a warm and loving manner Loneliness in dementia, is best treated with involvement of the person with the most positive relationship with the agitated patient, for that person to interact with the patient in a warm and loving manner. Other interventions found useful are one-to-one interaction with a new caregiver, videotapes of family members, contact with animals, massage therapy,and simulated presence therapy, in which the family caregiver tapes his or her side of a telephone conversation that is played for the patient as a repeated phone conversation.[2].
Touch therapies Hand massage intervention helps decrease aggressive behaviors, and expressive physical touch intervention helps lower anxiety and decrease episodes of dysfunctional behaviors.[2].
General measures to improve sleep A number of approaches have been taken to improve sleep and thereby decrease agitation, use of bright light therapy,use of melatonin, increased exercise, and a decrease in nighttime interruptions.[2].
Reassurance and distraction Both aggressive and verbally agitated behaviors have been successfully treated by manipulating reinforcing consequences of these behaviors. Reassurance and distraction may be sufficient for many patients.[2].
Listening to music Music helps decrease aggressive behaviors in people with dementia, relieves anxiety and agitation, promotes relaxation, provides opportunity for reality orientation and access to memory, provides cognitive stimulation, increases attention span, increases socialization (even in withdrawn patients) and social skills, and improves quality of life in dementia patients. Consider use of soothing music at meal times and patients' preferred music at bath time. Individualized music (music that has been integrated into the individual's life and is based on personal preference) may decrease agitation in dementia patients.[2].
Simulated presence therapy Audiotapes of family conversation or telephone messages and/or videotapes of family events and functions are played while residents listen on headphones or watch on the video.[2].
Regular exercise Regular exercise such as walking may reduce aggression.[2].
Simple cognitive activities Bingo can be of great value to the daily management of dementia patients.Reading a newspaper or a story is another useful activity. Sorting is also a good activity. For example, colored macaroni or pasta shells can be sorted into different piles, as can nuts of different shapes and napkins of different colors. Avoid using small items such as marbles that may be inadvertently ingested.[2].
Rocking chair intervention The use of rocking chairs has been found to decrease depression and anxiety.[2].
Pet therapy Pet therapy has been found to reduce the number of agitated behaviors in persons with dementia.[2].
Refere to Dementia Special Care Units Residents with dementia can be disruptive to other residents, difficult to manage, and challenging to health care professionals charged with their care. Special care units may help ensure superior quality of care for dementia patients, especially those at risk of wandering out of the facility and who are difficult to redirect back.[2].
References
  1. MARKOWITZ JD, NARASIMHAN M. Delirium and Antipsychotics: A Systematic Review of Epidemiology and Somatic Treatment Options Psychiatry (Edgmont) [online] , 5(10):29-36 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695757
  2. DESAI AK, GROSSBERG GT. Recognition and Management of Behavioral Disturbances in Dementia Prim Care Companion J Clin Psychiatry [online] 2001, 3(3):93-109 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181170

Management - Specific Treatments

Fact Explanation
Hypnotics Two hypnotics, zolpidem, a short-acting hypnotic, and zaleplon, a new, even shorter-acting hypnotic, have demonstrated efficacy in the treatment of elderly individuals with insomnia and may provide advantages over benzodiazepines in dementia patients. The preferred dose of zolpidem is 5 mg and that of zaleplon is 5 or 10 mg. Use of hypnotics should be only for a short term (a few days to 3 weeks), after careful assessment of risks and benefits, and should always be accompanied by measures to improve sleep hygiene.[1].
Antidepressants Citalopram, a selective serotonin reuptake inhibitor (SSRI), was found to be useful in a range of symptoms (including depression and agitation) in dementia patients.Fluoxetine has been found to be useful for major depression complicating Alzheimer's disease. Placebo-controlled trials with mixed dementia populations have shown nonsignificant improvement in symptoms common in behavioral and psychological symptoms of dementia such as irritability, anxiety, fear/panic, mood, and restlessness with fluvoxamine and significant improvements in depression with paroxetine. Fluoxetine was reported to slightly improve disinhibition, depressive symptoms, carbohydrate craving, and compulsions.[1].
Mood Stabilizers Anticonvulsants may provide an alternative to antipsychotics for aggression and agitation in dementia patients.An early pilot study displayed the potential for 300 mg of carbamazepine to decrease impulsive or aggressive behaviors; when the medication was withdrawn, the behavioral disturbances relapsed. A recent study did not find divalproex sodium to improve signs and symptoms of mania associated with dementia in a sample of nursing home residents, but divalproex did improve symptoms of agitation.Divalproex at doses of 150 to 250 mg decreased agitation and aggression in one pilot study.The elderly may have a higher risk of developing thrombocytopenia with valproate.Gabapentin has also been found to be useful in reducing agitation and aggression in patients with dementia.[1].
Trazodone and Buspirone Trazodone, in a number of open-label studies, was found to improve behavioral symptoms in demented elderly patients.Trazodone may be tried for anxiety and insomnia not responding to nondrug interventions. Twenty-five milligrams at bedtime for insomnia or twice a day for anxiety is a good starting dose. Orthostasis may be seen, especially at higher doses. Buspirone may be tried if the patient shows symptoms of persistent or generalized anxiety.[1].
Electroconvulsive Therapy Electroconvulsive therapy has been reported to improve depression, screaming, and agitation in dementia patients. Such treatment interventions may be considered in an academic setting, by geriatric psychiatrists experienced in severe cases of behavioral disturbances refractory to other interventions.[1].
Thiamine Withdrawal from alcohol or other illicit substances requires specific treatment and must not be confused with other types of delirium in the elderly postoperative patient. Former alcoholics should receive thiamine, which is the key drug for the management of Korsadoff’s psychosis.[2].
References
  1. DESAI AK, GROSSBERG GT. Recognition and Management of Behavioral Disturbances in Dementia Prim Care Companion J Clin Psychiatry [online] 2001, 3(3):93-109 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181170
  2. ROBINSON TN, EISEMAN B. Postoperative delirium in the elderly: diagnosis and management Clin Interv Aging [online] 2008 Jun, 3(2):351-355 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546478