Pharmacotherapy for non-cognitive symptoms targets psychotic symptoms, inappropriate or disruptive behavior, and depression. General guidelines include the following: (1) Use environmental interventions first and pharmacotherapy only when necessary; (2) identify and correct underlying causes of disruptive behaviors when possible; (3) start with reduced doses and titrate slowly; (4) monitor closely; (5) periodically attempt to taper and discontinue medication; and (6) document carefully.
Avoid anticholinergic psychotropic medications as they may worsen cognition. Cholinesterase Inhibitors and Memantine Cholinesterase inhibitors and memantine have shown modest improvement of behavioral symptoms over time but may not significantly reduce acute agitation.
Antipsychotic medications have traditionally been used for disruptive behaviors and neuropsychiatric symptoms, but the risks and benefits must be carefully weighed. A meta-analysis found that only 17% to 18% of dementia patients showed a modest treatment response with atypical antipsychotics.
Adverse events (eg, somnolence, extrapyramidal symptoms, abnormal gait, worsening cognition, cerebrovascular events, and increased risk of death [see black-box warning]) offset advantages. Another systematic review and meta-analysis found small but significant improvement in behavioral symptom scores in patients treated with aripiprazole, olanzapine, and risperidone.
Typical antipsychotics may also produce a small increased risk of death, and more severe extrapyramidal effects and hypotension than the atypicals. Antipsychotic treatment in AD patients should rarely be continued beyond 12 weeks.
Depression and dementia share many symptoms, and the diagnosis of depression can be difficult, especially later in the course of AD.A selective serotonin reuptake inhibitor (SSRI) is usually given to depressed patients with AD, and the best evidence is for sertraline and citalopram. Tricyclic antidepressants are usually avoided.
Use of benzodiazepines is not advised except on an “as needed” basis for infrequent episodes of agitation. Carbamazepine, valproic acid, and gabapentin may be alternatives, but evidence is conflicting.