Behavioral and Psychological Symptoms in Dementia: The Role of Atypical Antipsychotics

Although cognitive dysfunction is the hallmark of dementia, behavioral and psychological symptomsof dementia (BPSD), such as psychosis, aggression, sleep disturbance, agitation, and mood disorders,develop in most elderly patients at some stage. These symptoms pose major difficulties in theday-to-day care of patients and are likely to impair the quality of life of both patient and caregiver.Patients exhibiting BPSD should be assessed in a detailed clinical interview to establish symptomscausing distress to the patient and/or caregiver. Several mood and behavior scales with good psychometricproperties are available for patient evaluation. Initial intervention should focus on nonpharmacologicmeasures, and the quality of patient care should be optimized with potential physical, environmental,social, and psychiatric triggers being addressed where possible. Caregiver education, support,and behavioral training can also be effective in alleviating BPSD. However, pharmacologic interventionis necessary in many cases and includes use of antidepressants for mood disorders, anticonvulsantsfor nonpsychotic agitation, and antipsychotics for aggression, agitation, and psychotic symptoms.Conventional antipsychotics have shown modest benefit over placebo in the treatment ofpsychosis and agitation in dementia patients; however, they are associated with treatment-emergentside effects, particularly extrapyramidal symptoms (EPS). Atypical antipsychotics such as risperidone,olanzapine, and quetiapine are at least as effective as conventional antipsychotics, are bettertolerated, and have a lower propensity for EPS. There are, however, significant differences betweenatypical agents with regard to receptor affinities and, therefore, side effect profiles. Patients’ vulnerabilityto these side effects should be considered when making individual treatment decisions.