The value of centrally acting cholinergic agents and glutamate antagonists in the treatment of Alzheimer disease is modest but clear and should be weighed against the need for blood testing and side effects. These medications, however, may offer psychologic benefit to the patient and family if they do not worsen behavior or increase hallucinations; they are not appropriate for advanced stages of disease. Chapter 38 discusses the use of these medications.
Undesirable restlessness, nocturnal wandering, and belligerency may be reduced by administration of one of the antipsychotic or benzodiazepine drugs. Randomized trials and observational studies of these drugs show no benefit and may increase overall mortality rates (see the meta-analysis by Schneider and colleagues), in many circumstances there are few other options. Experts recommend behavioral approaches to these problems. Nevertheless, if reorientation, calming environmental changes, reassurance, and presence of family members and staff do not reduce anxiety, emotional lability and paranoid tendencies, there may be a need for the judicious use of low doses of quetiapine, olanzapine, risperidone, or haloperidol. Some patients are helped by short-acting sedatives such as lorazepam without any worsening of the mental condition, but all these drugs must be given with caution and some may be particularly problematic in patients with combined parkinsonism and dementia syndromes.
Questions asked by the patient’s family must be answered patiently and sensitively by the physician. Common questions are “Should I correct or argue with the patient?” (No.) Orientation as to date, circumstances, and planned appointments is, however, helpful in preparing the patient for the day activities. “Can the patient be left alone?” “Must I be there constantly?” (Depends on specific circumstances and the severity of dementia.) “Should the patient manage his own money?” (Generally not.) “Will a change of environment or a trip help?” (Generally not; often the disruption in daily routine worsens behavior and orientation.) “Can he drive?” (Best to advise against driving in most instances.) “What shall we do about the patient’s fears at night and his hallucinations?” (Medication under supervision may help.) “When is a nursing home appropriate?” “How will the condition worsen? What should the family expect, and when?” (Uncertain, but usually a 5to 10-year course.) Many families have found the information on the Alzheimer Association website, http://www.Alz.org, helpful, but physician guidance is required to make the material applicable to individual circumstances.
Visiting nurses, social agencies, live-in healthcare aides, day care settings, and respite care to relieve families from the constant burden of caring for the patient should all be used to advantage. Some of the inevitable practical problems accompanying the dissolution of personal life caused by dementia can be ameliorated by judicious use of powers of attorney or guardianship and similar legal vehicles.
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