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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #3, #24, #57, #59, #60, #62


Learning Objectives

  • Learn the epidemiology, pathophysiology, and common behavioral problems seen in patients with dementia.

  • Understand the best approach to evaluate neuropsychiatric symptoms in patients with dementia, and effective strategies to manage such symptoms.

  • Learn about the significance and efficacy of nonpharmacologic interventions and appropriate indications, limitations, and adverse effects of antipsychotic medications.

  • Acquire a clear understanding of the important role that supportive care plays in reducing caregiver stress and improving behavioral symptoms in patients with dementia.

Key Clinical Points

  1. Behavioral symptoms are seen in up to 98% of patients with dementia and are the result of high-order loss of behavioral control and involvement of major neurobiological networks and neurotransmitters.

  2. Patients with neuropsychiatric symptoms have higher mortality and progress more rapidly from mild to severe stages of dementia.

  3. Careful history-taking is essential and exclusion of delirium is paramount for proper diagnosis and management of behavioral symptoms associated with dementia.

  4. Onset of new behavioral symptoms in patients with dementia, especially systematized delusions should suggest onset of another psychiatric disorder, such as a major depressive disorder with psychotic features or schizophrenia.

  5. Nonpharmacologic interventions should be the first-line treatment and antipsychotics should be avoided as much as possible, given their lack of efficacy in randomized trials and higher incidence of side effects.

  6. Appropriate indications for antipsychotic medications include failure of nonpharmacologic therapies and presence of neuropsychiatric symptoms severe enough to interfere with the patient’s overall quality of life and function.


Dementia is epidemic. It is a leading cause of disability in developed countries. Alzheimer Disease International estimates there were approximately 35.6 million individuals living with dementia worldwide in 2010. The number of people living with dementia worldwide is expected to approximately double every 20 years to 65.7 million in 2030 and 115.4 million in 2050. Seventy percent of dementia is due to Alzheimer disease (AD) and the Alzheimer’s Association estimates there are 5.2 million Americans currently living with AD. Dementia can have grim effects on those afflicted with the syndrome, their families, and society.

Neuropsychiatric symptoms (NPS) are nearly universal in dementia, affecting up to 98% of individuals across dementia stages and etiologies. NPS tend to persist over time. Around 80% of individuals with dementia at baseline demonstrate at least one symptom across an 18-month interval. Over time, the number of NPS increase with the most common symptoms being depression, apathy, agitation, and restlessness (75% of individuals with dementia will manifest at least one of these symptoms), followed by sundowning and verbal outbursts (50% of individuals will manifest one of these).

NPS are associated with increased morbidity and mortality, decline in cognition and function, increased rate of disease progression, earlier nursing home placement, and increased health care utilization. NPS are also associated ...

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