Dementia: Managing Challenging Behaviours Associated with Dementia

Table 2 Medications for the treatment of dementia

Medication	Donepezil	Galantamine (Reminyl)	Rivastigmine (Exelon)	Memantine (Ebixa)
Initial Dose^a	5 mg	4 mg po bid (regular) 8 mg po od (extended release XR)	Oral 1.5 mg po bid Patch: One 5 cm² patch daily	5 mg po od
Titration schedule	Increase by 5 mg every 4 weeks	Increase by 8 mg every 4 weeks	Increase by 3 mg in divided doses every 4 weeks Patch: Increase to one 10 cm2 patch daily after 4 weeks	Increase by 5 mg every week, start by adding second 5 mg dose
Maximum dose	10 mg	12 mg po bid 24 mg po od	6 mg po bid	10 mg po bid
Formulations	Tablet	Immediate release tablets taken bid, extended release tablet taken once daily	Tablet taken bid Transdermal patch, recently released, which is applied daily	Tablet taken bid
Indications	Mild to moderate Alzheimer's disease	Mild to moderate Alzheimer's disease	Mild to moderate Alzheimer's disease	Adjunctive treatment added to cholinesterase inhibitor therapy in moderate to severe Alzheimer's disease
Other potential indications	Mixed dementia, Parkinson's dementia, Lewy body dementia	Mixed dementia, Parkinson's dementia, Lewy body dementia	Mixed dementia, Parkinson's dementia, Lewy body dementia
Side-effects	Contra-indicated with history of sick-sinus syndrome, left bundle branch block (due to risk of bradycardia), recent peptic ulcer disease Common side-effects (MIND): - Muscle craps - Insomnia - Nausea - Diarrhea	Similar to donepezil	Similar to donepezil Gastrointestinal side-effects often more pronounced	Common side-effects (CHECK): - Confusion - Headache - Equilibrium (dizziness) - Constipation - Kidney (requires dose adjustment in renal failure as per CPS)
Other notes				At publication, not covered on provincial drug formularies; cost is ~$200/ month

All cholinesterase inhibitors should be given in the morning to minimize sleep disturbance. Lower starting doses and slower dose titration may be necessary in some patients who are sensitive to side-effects.

Evaluating and Treating Behavioural and Psychological Symptoms

The ABC approach involves clear steps for obtaining an accurate description of the problem behaviour:

What are the Antecedents to the behaviour?
What exactly is the Behaviour? (Be more specific than “agitated” or “aggressive.”)
What is the Consequence (caregiver’s response) of the behaviour?

After getting a clear description, the next step is to rule out potential reversible secondary causes of the behaviour. Evaluate delirium risk in a systematic and comprehensive way by using the three-question template on pages 231–233 (What has changed? What are the risks and causes? What is the action?). Delirium can present with behavioural disturbances in patients with dementia and should first be ruled out (see Figure 12.1 on page 222 for an algorithm for diagnosing delirium). Be aware of potential medical indications conditions, including pain, that can exacerbate behaviours, as well as unmet needs, constipation and environmental contributors.

Initiate non-pharmacological management for the specific behaviours. Provide education to caregivers, which can often decrease distress and negative responses to the behaviours. You may need to consider pharmacological treatments early if the behaviours endanger others or cause extreme distress.

To determine the impact of the behaviour and the risks associated with it, and to monitor response, use the four Ds approach:

Is the behaviour Dangerous, Distressing, Disturbing relationships or jeopardizing independence due to the effects on the caregivers, and/or causing Disability (e.g., medical malnutrition, risk for falls)?

If the behaviour persists, optimize the treatment of the underlying dementia. This may include taking measures to prevent further cognitive decline as well as prescribing cognitive enhancers.

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Managing Challenging Behaviours Associated with Dementia

Evaluating and Treating Behavioural and Psychological Symptoms