A comprehensive review of the mental health problems and needs that are characteristic of patients who suffer behavioural and psychological symptoms of dementia.
Alois Alzheimer’s 1901 case report decribes a woman who presented with ideas of jealousy toward her husband as her first apparent sign of illness. Soon, rapidly worsening cognitive deficits were noticeable; she was profoundly disorientated, showed signs of purposeless hyperactivity, demonstrated hoarding behaviour ,at times she had paranoid delusions believing that she was about to be murdered and often yelled out loudly.
The DSM and ICD – 10 criteria for the diagnosis of Dementia, including that of resultant of Alzheimer pathology is based entirely on deficits on cognitive function including amnesia,aphasia and apraxia along with functional decline, although it is clear that other non cognitive symptoms were well described even in this earliest description of Alzheimer’s Disease.
The behavioural and psychological symptoms of dementia, also known as neuropsychiatric symptoms represent a heterogenous group of non- cognitive symptoms and behaviours which are observed in patients who suffer dementia. These symptoms represent a major component of the dementia syndrome, irrespective of the pathological subtype of the disease.
Behavioural and psychological symptoms of dementia include agitation, aggression, psychosis, sleep disturbance, hallucinations, disinhibition, apathy and depression. It is estimated that one of these symptoms will affect up to 90% of dementia sufferers over the course of their illness, and their presence is independently related to poor outcomes, including distress to patients and their carers, admission to long term care facilities, misuse of medication and increased healthcare costs. In consideration of the burden these symptoms of dementia exert on the individual sufferer, their carers and their wider cost to society they are as an important clinical target for intervention as the cognitive deterioration seen in dementia syndromes.
It is usual to observe more than one of these symptoms simultaneously in a dementia sufferer. The pathogenesis of behavioural and psychological symptoms of dementia has not been clearly defined, however they are likely to be the result of a complex causal relationship between social, psychological and pathological factors.
Although encompassed under the umbrella term of neuropsychiatric symptoms, these symptoms are diverse and effective interventions are directed at singular symptoms. During the remainder of this paper symptom specific patient needs along with potential treatment strategies will be discussed.
Depression alone can produce symptoms and signs of cognitive impairment, particularly in elderly patients, a phenomenon called depressive pseudodementia. Older people who become depressed are at increased risk of developing dementia. The risk of developing AD associated with premorbid depression may be higher in men than women, and it may be independent of vascular disease(14).Patients with dementia may develop apathy, sleep impairment, and social withdrawal that suggest the presence of depression, but that are entirely due to cognitive deficits.
Apathy is a separate feature of the dementia syndrome, which is defined as a disorder of motivation with additional loss of goal- directed behaviours, cognitive activities and emotions. This can be misdiagnosed as depression, but apathy is a lack of motivation without dysphoria.Patients with dementia may become depressed in reaction to slipping mental capacity or as a direct biological consequence of the underlying neurologic disorder.
Further complicating the clinical picture, patients with depression or dementia, let alone those with both, often cannot offer much illumination on their own mood or mental ability.
The symptoms of depression that would usually allow the condition to be diagnosed such as expressed feelings of sadness, loss of self esteem and