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Alzheimer’s Disease: The Gray Tsunami

 

In the growing epidemic of Alzheimer’s Disease (AD) and related disorders, the most salient discussion centers on the increasing costs and societal implications of an aging population. Less noted but more influential in day-to-day care are the behavioral and/or psychological symptoms of dementia (BPSD).

 

Approximately 90 percent of patients affected by AD and related disorders will experience one or more significant BP SD. In 30 percent of those cases, the symptoms will have a significant effect on quality of life for both patients and caregivers. To a large extent, the degenerative disorders are really “social” disorders in that they have a major impact upon the people around them as well as society at large.

 

The International Psychogeriatric Association classifies symptoms like aggression, agitation, socially inappropriate behaviors, restlessness and verbal outbursts as behavioral components, while anxiety, delusions, depression and hallucinations are cataloged as psychological components.

Robert Harbaugh, MD


Case Study:
Lewy Body Disease >>


 

Current research suggests the complex mechanisms behind these aspects of AD and dementia stem from a loss of connectivity in the emotional and information-processing hubs of the brain.

 

The Dementia Point of View

BP SD are a complex set of disorders of the mind that arise from longstanding personality traits, co-existent psychiatric disorders, or more commonly, evolve as a direct result of the devastating direct effects of dementia on the brain. When the causes are understood in that context and coupled with the realization that behavior is a form of communication, it is easier to appreciate why a nursing home patient with AD would express fear when a nurse arrives to perform a morning ritual like a bath.

 

In conceptualizing how the AD patient might view the world, imagine having virtually no short-term memory, so each “new” visit by one’s nurse or even spouse is that of a stranger. Aggression and fear are the natural responses when a person interprets the interaction as a stranger trying to take his or her clothes off, as the patient would view the nurse’s visit. It would be natural for that patient to express anxiety and feel threatened when the professional home aid or spouse simply tries to bathe the affected person, leading in this case to an exhibition of verbal and physical aggression, which is only “natural” as a self-defensive behavior in the mind of the demented patient. Negotiations and a firm confrontational approach will only exacerbate this potentially explosive situation. This illustrates only one common, daily BP SD challenge, which requires a combination of behavioral and pharmacological approaches to improve all parties’ quality of life.

 

Management of BP SD begins with non-pharmaceutical approaches, wherein caregivers and physicians employ behavioral strategies such as exercise, humorous or calming distractions, and non-verbal reassurances.

 

Securing Patient Safety

Pharmaceutical management becomes necessary when a patient’s BP SD develops to the point of affecting his or her wellbeing or a caregiver’s quality of life. Treatment is determined according to a prioritization of individual behaviors and carefully titrated.

 

Specialists at Santa Barbara Neuroscience Institute at Cottage Health System have found a select group of medications effective in symptom management. These medications are prescribed at a low dosage and then gradually titrated to the appropriate dose. When carefully chosen, the right combination of medications, in addition to caregiver education and support from the medical community, can affect great benefits to a patient’s and his or her caregiver’s quality of life.

 

To meet to the specialists at Santa Barbara Neuroscience Institute at Cottage Health System, visit www.sbni.org.

 

 

"Managing BPSD [behavioral and/or psychological symptoms of dementia] requires creative approaches that focus upon non-pharmacological strategies. However, over the past 15 years, a dramatic and quiet revolution in better medication options has occurred. Although, surprisingly, there are no FDA-approved drugs for BPSD, experienced clinicians can employ a ‘start low, go slow, but don’t stop’ philosophy for most affected patients. Targeting the most problematic BPSD and taking the utmost caution to avoid creating a chemical straightjacket has been a gratifying approach for most families.”

— Robert Harbaugh, MD, neurologist at Santa Barbara Neuroscience Institute


 

Case Study: Lewy Body Disease

 

A 72-year-old, right-handed, white married male presented to his primary care physician’s office with a two-year history of “fluctuating” confusion.

 

The patient describes no family history of neurological diseases. Born, raised and educated in the Midwest, he completed his graduate work in electrical engineering at a prestigious East Coast university and founded a small, successful electronics company. He had enjoyed excellent health throughout his life.

 

However, his wife noted subtle changes in his personality had begun approximately five years before he presented for examination. One year earlier, after a routine knee arthroscopy, the patient manifested several days of marked confusion and hallucinations. In addition, the patient developed violent dreams at night, during which he would swing his arms at his wife while she slept. The patient became lost on three occasions while walking to meet friends two blocks from his house.

 

During the recent flu epidemic, the patient became severely “delirious” and had difficulty walking for several weeks after becoming ill. During this time, the patient also developed an unusual tremor of the arms, which had since dissipated. His prior athleticism declined significantly; a top-tier tennis player eight years earlier, he now struggles to return a ball. The patient has turned over his financial affairs to his wife.

 

Referral for Neurological Examination

With the exception of mild hypertension and intermittent osteoarthritis of the spine and knees, the patient enjoys excellent physical health. He currently takes only losartan and occasional Advil. His screening physical exam was essentially unremarkable, except for non-specific changes in gait and some “slowing down” according to his primary care physician. Routine laboratory studies are unremarkable.

 

A neurological consultation was pursued and, in addition to the history provided above, the patient admitted to more frequent visual apparitions associated with mild paranoia. In addition, the patient developed severe insomnia, had become very depressed over the past three months and developed severe daytime sleepiness.

 

The neurological examination demonstrated a moderately depressed 72-year-old male with a mild gait disorder associated with a subtle postural tremor of both arms, left greater than right. Mental status examination suggested visuospatial impairment. A mini-mental status exam was 25/30. The remainder of the exam was essentially unremarkable.

 

The possibility of a degenerative central nervous system disorder, specifically Lewy Body Disease, was raised by the neurologist. A magnetic resonance imaging (MRI) brain scan and full neuropsychological profile was ordered. The patient was placed upon rivastigmine transdermal (Exelon Patch) and was seen seven weeks later. The MRI brain scan was unremarkable for age. Psychometrics demonstrated mild deficits in several areas including visual and verbal memory, both short- and long-term, as well as substantial impairment in spatial skills.

 

Diagnosis and Management

When seen two months later, the patient was “remarkably” better, according to his family, but nocturnal rapid eye movement sleep behavior appeared to worsen. A sleep study was discussed, but instead a therapeutic trial of clonazepam was initiated with excellent results. An in-depth discussion of Lewy Body Disease subsequently followed, and the family was provided with several sources of educational materials, including the Central Coast Alzheimer’s Association.

 

The patient was able to remain at home for several years with careful medical management. He died of pneumonia at age 78.

 


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