Disturbances in behavior and mood are common and disabling aspects of dementia (Burns, Jacoby, and Levy, 1990; Katzman, 1985; Reisberg et al., 1987). They present significant problems for both family and professional care providers and are often cited as the most difficult aspect of caregiving, leading to greater functional impairment and increased caregiver burden. It is imperative, then, that healthcare providers be aware of the most effective ways to treat these problems. Pharmacological, behavioral, or social support interventions may, for example, delay the need for institutionalization when behavioral and mood disturbances are severe or cause safety concerns (Carlson et al., 1995; Mittelman et al., 1995, 1996; Steele et al., 1990), while failure to address these problems may compound the disability of patients and their caregivers.
This article will describe basic treatment of cognitively impaired older adults in community-based or institutional settings. It is not an exhaustive review but presents a straightforward approach to care. Practitioners interested in more comprehensive reviews of assessment and treatment research are referred elsewhere (e.g., Sky and Grossberg, 1994.; Teri et al., 1992; Weiner et al., 1996).
GUIDELINES FOR TREATMENT
Behavioral, pharmacological, and combined therapies all require a systematic assessment of the underlying dementia and of the history, course, and presentation of the behavioral and mood disorders (see Weiner et al., 1996). The following general guidelines for clinicians for the treatment of behavioral and mood impairments illustrate a sound, basic approach to care.
Acute onset problems often suggest acute med ical illness. The clinician should first evaluate whether a medication change, metabolic derangement, acute infection, or injury is related to the behavioral disturbance. A patient with dementia may be unable to accurately describe symptoms or events, and thus behaviors may be the best indicator of the presence of a physical disorder. Environmental changes, including unfamiliar places, a change in caregivers, or a frightening experience may trigger abrupt behavioral changes. In such cases, the clinician should address the cause directly or allow time for adjustment before instituting a comprehensive treatment program.
Chronic medial conditions may cause or contribute to behavioral and mood disturbances. Medication side-effects may develop slowly over time, and should be considered as a possible cause of behavioral disturbance. Chronic pain caused by arthritis or other degenerative conditions as well as impaired vision or hearing may also contribute to behavior or mood problems. If underlying medical conditions are present, they should be addressed prior to treating behavioral or mood disturbances.
Episodic outbursts typically imply that the behavior is influenced by the patient's environment. Hunger, fatigue, changes in caregiving staff, and over- or understimulation are often linked to behavioral or mood disturbances. When behavior problems occur only at night, on weekends, in a particular location, or with a specific person, changing the environment may be the most effective treatment.
Caregiver involvement must be assessed to determine the type of treatment that will be most realistic and helpful. For example, patients who live alone will require a different approach compared to patients who live with a full-time caregiver. Further, the caregiver's own health, cognitive, and psychosocial status will affect the ability to participate in the patient's treatment. Clearly, caregivers need support. (See Logsdon et al., 1997, and Zarit, Orr, and Zarit, 1985).
Safety of patient and caregiver must be considered when deciding on a course of treatment. If a dangerous behavior is occurring, ensuring safety must be the priority.
Nonpharmacological approaches or behavioral interventions are often the appropriate initial strategy. …