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Learning Objectives

  • Learn the presentation, epidemiology, and pathophysiology of common neuropsychiatric symptoms (NPS), including behavioral disturbances, seen in patients with dementia.

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

  • Learn about the significance and efficacy of nonpharmacologic interventions.

  • Understand the appropriate indications, limitations, and adverse effects of pharmacologic interventions.

Key Clinical Points

  1. NPS are seen in up to 98% of patients with dementia and are the result of high-order loss of behavioral control due to disease involvement of major brain networks and neurotransmitters.

  2. Patients with NPS have higher mortality and progress more rapidly from mild to severe dementia.

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

  4. Onset of new NPS in patients with dementia, especially systematized delusions, can be mistaken for 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 adverse treatment effects.

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

  7. If medications are started, use slow titration, use the lowest effective dose, and reassess its risk/benefit ratio on a regular basis.


It is estimated that 5.3 million Americans live with Alzheimer disease (AD), the most common cause of dementia, and that 13.8 million people older than 65 years will be diagnosed in the United States by 2050. In the United States, annual health care costs for persons with AD are more than $172 billion, including $123 billion in costs to Medicaid and Medicare alone.

Neuropsychiatric symptoms (NPS) affect almost all persons with dementia over the course of illness. Although cognitive deficits are the hallmark of dementia, almost 98% of patients with AD experience depression, agitation, anxiety, psychosis, hallucinations, apathy, eating disorders, disinhibition, and/or sleep disturbances. Depression, apathy, and anxiety are the most common NPS in dementia. NPS are also present in the prodromal or mild cognitive impairment (MCI) stages of dementia. Depression and irritability are common even prior to the onset of MCI and dementia and appear to be the first symptoms of well over half of people who later develop dementia. Late-life onset of NPS of any severity in individuals without dementia, lasting for over 6 months, that are not attributable to another concurrent psychiatric disorder (such as major depressive disorder) are now referred to as mild behavioral impairment (MBI). While NPS are seen at all stages of dementia, including prior to cognitive decline, the severity of NPS increases with progressive cognitive decline both in community and nursing home populations.

The impacts of NPS on both patients ...

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