From the Guidelines
Managing an 80-year-old gentleman with vascular dementia and behavioral disturbances requires a comprehensive approach combining non-pharmacological and pharmacological interventions, with a strong emphasis on non-pharmacological strategies as the first-line management. This approach is supported by the Canadian Stroke Best Practice Recommendations: Vascular Cognitive Impairment, 7th edition practice guidelines update, 2024 1.
Non-Pharmacological Interventions
Non-pharmacological strategies should be considered as the first-line management for individuals with vascular cognitive impairment (VCI) who are displaying behavior changes 1. These strategies include:
- Structured and tailored activities that are individualized and aligned to current capabilities and take into account previous roles and interests 1
- Cognitive behavioral, interpersonal, and/or problem-solving deficits, psychotherapeutic strategies may be considered to facilitate adaptive coping 1
- Simulated presence therapy (SPT), using audio or video recordings prepared by family members or surrogates and including positive experiences from the participant’s past life, can reduce symptoms of agitation in individuals with severe dementia living in nursing homes 1
- Massage therapy, animal-assisted interventions, personally tailored interventions, and even pet robot interventions have been shown to help agitation 1
Pharmacological Interventions
If pharmacological treatment of behavior is required, SSRIs are considered first-line treatments for agitation 1. For depression symptoms, sertraline 25-50mg daily or citalopram 10-20mg daily may help 1. Antipsychotics like risperidone can be used for severe agitation or aggression but should be limited to 6-12 weeks due to increased stroke risk 1.
Safety and Risk Management
Assessment of individuals for potential safety risks is crucial, including understanding the relationship between the individual’s cognitive status and attributes such as autonomy, behavioral status, environment, risk for falls, and activities and occupations 1.
Caregiver Support
Caregiver education and support are crucial components of the overall management plan, as they play a significant role in providing care for their family member or friend and being a partner in care 1.
By prioritizing non-pharmacological strategies and carefully selecting pharmacological interventions when necessary, while also focusing on safety and caregiver support, the management of an 80-year-old gentleman with vascular dementia and behavioral disturbances can be optimized to improve his quality of life and reduce morbidity and mortality.
From the FDA Drug Label
WARNINGS AND PRECAUTIONS SECTION 5. 1 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. RISPERIDONE (risperidone) is not approved for the treatment of dementia-related psychosis [see Boxed Warning].
The treatment of an 80-year-old gentleman with vascular dementia and behavioral disturbances should not include risperidone due to the increased risk of mortality and other adverse effects associated with its use in elderly patients with dementia-related psychosis 2.
- Alternative treatments should be considered to manage behavioral disturbances in this patient population.
- Non-pharmacological interventions may be preferred to minimize the risk of adverse effects.
- Careful evaluation of the patient's condition and consideration of the potential risks and benefits of any treatment are necessary before making a decision.
From the Research
Treatment Approach
To treat an 80-year-old gentleman with vascular dementia and behavioral disturbances, a multifaceted approach is recommended 3. This approach should prioritize non-pharmacological interventions and focus on supporting the patient's dignity, comfort, and quality of life.
Identifying Behavioral Disturbances
Common behavioral disturbances in dementia can be grouped into four categories:
- Mood disorders (e.g., depression, apathy, euphoria)
- Sleep disorders (insomnia, hypersomnia, night-day reversal)
- Psychotic symptoms (delusions and hallucinations)
- Agitation (e.g., pacing, wandering, sexual disinhibition, aggression) 3
Vascular Dementia Considerations
Vascular dementia (VaD) is the second most common cause of dementia, accounting for about 20% of all cases 4. Patients with VaD often manifest symptoms related to damage to the frontal-subcortical system of the brain, including loss of executive function, loss of drive, and disinhibited behaviors 4.
Management Strategies
Management of behavioral disturbances in VaD involves:
- Prompt treatment of reversible factors
- Individualized non-pharmacological interventions
- Pharmacological interventions restricted to behavioral emergencies and short-term treatment of behavioral disturbances that pose imminent danger to self or others 3
- Consideration of the patient's specific pathology, as multiinfarct dementia and subcortical vascular dementia may exhibit different behavioral alterations 5
Effective Interventions
Effective interventions for behavioral disorders in dementia include:
- Memory therapy
- Ergotherapy
- Music therapy
- Physical exercise
- Antidementia drugs (e.g., galantamine, donepezil, rivastigmine, memantine)
- Risperidone for agitation and aggressiveness
- Citalopram for depression 6