Treating Psychiatric Illnesses

Treatment of Psychiatric Symptoms

The principal treatable neuropsychiatric disturbances in AD are:

• Agitation
• Depression
• Psychosis
• Anxiety

Patients with AD may respond well to antipsychotics, antidepressants, anticonvulsants, and other psychopharmacological (medicines for the treatment of psychiatric disturbances) agents. Target symptoms should be clearly specified and documented and the treatment response should be evaluated regularly.

Agitation occurs in as many as 70% of patient with AD and is more common as the disease progresses. Classes of agents used to treat agitation include antipsychotics, mood-stabilizing anticonvulsants, trazodone, anxiolytics, and beta-blockers. Available evidence suggests that antipsychotics, trazodone, or anticonvulsants have the greatest effectiveness in reducing agitation. Atypical antipsychotic agents such as clozapine, risperidone, olanzapine, quetiapine, and ziprasidone appear to have advantages over the older antipsychotic agents based on their side effect profiles and the patients' ability to tolerate them.

Psychosis is common in AD, with a frequency of about 50% over the lifetime of an AD patient. Atypical antipsychotics are the treatment of choice. Risperidone and olanzapine have an established benefit in this regard and quetiapine and ziprasidone may be useful. Sedation (dullness, calmness) is the most common side effect noted in patients receiving antipsychotics.

Depressive symptoms are frequent in AD and occur in as many as 50% of patients. Major depression is more unusual. The treatment of depressive symptoms commonly consists of selective serotonin reuptake inhibitors (SSRIs), such as sertraline, citalopram, or fluoxetine. Full doses of the SSRIs are generally tolerated in the elderly, which is unlike most other psychotropic agents wherein lower doses are typically used. Alternatively, tricyclic antidepressants with few anticholinergic (dry mouth, constipation, memory problems) side effects, such as nortriptyline, or combined noaradrenergic and serotonergic reuptake inhibitors, such as venlafaxine, have been used.

Anxiety is a common symptom in AD and affects 40% to 50% of patients at some point in the course of the illness. Most patients do not require medicines for the treatment of their anxiety. For those requiring medicines, benzodiazepines are best avoided because of their potential adverse effects on the thinking process. Nonbenzodiazepine anxiolytics, such as buspirone or SSRIs, are preferred.

Difficulty sleeping (insomnia) occurs in many patients with AD at some point in the course of their disease. Agents that are useful in treating insomnia in AD patients include moderately short-acting benzodiazepines, such as temazepam, nonbenzodiazepine sedative hypnotics, such as zolpidem or zaleplon, or sedating antidepressants, such as trazodone. Sleep improvement measures, such as sunlight, adequate treatment of pain, and limiting nighttime fluids, should also be implemented.