From the Guidelines
People living with Alzheimer's disease experience changed behavior primarily due to progressive damage to brain cells and neural connections, which can be managed with non-pharmacological interventions and, in some cases, medication, as supported by the most recent study 1. The changes occur as abnormal protein deposits (amyloid plaques and tau tangles) accumulate in the brain, causing neuronal death and disrupting communication between brain regions responsible for behavior regulation. The frontal lobe, which controls impulse control and social behavior, and the temporal lobe, which manages emotions and memory, are particularly affected. As the disease progresses, individuals may exhibit agitation, aggression, wandering, apathy, depression, anxiety, sleep disturbances, and inappropriate social behaviors. These behavioral changes often result from the person's inability to process environmental stimuli properly, communicate needs effectively, or remember social norms. Additionally, the person may experience confusion, frustration, and fear as they struggle to make sense of their changing cognitive abilities and surroundings. Physical discomfort, medication side effects, and environmental factors like overstimulation or changes in routine can further exacerbate behavioral symptoms. Understanding that these behaviors stem from brain damage rather than intentional actions helps caregivers respond with patience and appropriate interventions, such as maintaining routines, creating calm environments, and using clear, simple communication, as recommended by 1 and 1. Non-pharmacological interventions, including psychological interventions like cognitive behavioral therapies (CBTs) and physical activity, have been shown to improve mood and reduce depressive symptoms in individuals with vascular cognitive impairment (VCI) 1. In cases where medication is necessary, selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatments for agitation, as they have been found to significantly reduce overall neuropsychiatric symptoms and agitation in individuals with VCI 1. Overall, a comprehensive approach that incorporates non-pharmacological interventions, medication, and caregiver support can help manage changed behavior in people living with Alzheimer's disease and improve their quality of life. Some key strategies for managing behavioral symptoms include:
- Providing a predictable routine and a safe environment
- Using distraction and redirection of activities to divert the patient from problematic situations
- Ensuring that comorbid conditions are optimally treated
- Using lighting to reduce confusion and restlessness at night
- Avoiding glare from windows and mirrors, noise from a television, and household clutter
- Reducing excess stimulation and outings to crowded places
- Considering using a day care program for patients with Alzheimer’s disease
- Registering the patient in the Alzheimer’s Association Safe Return Program and protecting them by appropriate use of locked doors and gates, as recommended by 1.
From the Research
Changed Behaviour in Alzheimer's Disease
People living with Alzheimer's disease often experience changed behaviour, which can be distressing for both patients and caregivers. The following points highlight the key aspects of changed behaviour in Alzheimer's disease:
- Agitation is a common symptom, affecting up to 60% of patients, and is associated with an imbalance of activity between key prefrontal and subcortical brain regions 2.
- The monoamine neurotransmitter systems, including noradrenergic, serotonergic, and dopaminergic systems, play a crucial role in modulating activity within these brain regions and circuits, and are rendered abnormal in Alzheimer's disease 2.
- Patients with Alzheimer's disease who exhibit agitation symptoms have alterations in neurotransmitter nuclei and related systems when the brain is examined at autopsy 2.
- Apathy is the most common behavioural change, exhibited by 72% of patients, followed by agitation, anxiety, irritability, and dysphoria 3.
- Agitation, dysphoria, apathy, and aberrant motor behaviour are significantly correlated with cognitive impairment 3.
Treatment and Management
Treatment and management of changed behaviour in Alzheimer's disease are crucial to improve patient outcomes and reduce caregiver burden. The following points highlight the key aspects of treatment and management:
- Memantine has been shown to be effective in reducing agitation and aggression in patients with moderately severe to severe Alzheimer's disease 4.
- Memantine treatment has been associated with significant benefits in cognitive, functional, and global outcomes in patients with Alzheimer's disease and agitation/aggression or psychosis 4.
- Biomarkers, such as neuropathological, neurotransmitter, neuroimaging, and inflammatory markers, have been identified as potential diagnostic markers for agitation and aggression in Alzheimer's disease 5.
- Further research is needed to investigate the predictive, prognostic, and monitoring capacity of biomarkers to provide insight into the longitudinal course of agitation/aggression and predict and monitor biological response to pharmacological interventions 5.
Non-Pharmacological Interventions
Non-pharmacological interventions, such as education of families, formation of Alzheimer units in nursing homes, and adjunctive psychotropic agents, are also important in managing changed behaviour in Alzheimer's disease. The following points highlight the key aspects of non-pharmacological interventions:
- Education of families and caregivers is essential to manage behavioural symptoms in patients with Alzheimer's disease 6.
- The formation of Alzheimer units in nursing homes can provide a supportive environment for patients with Alzheimer's disease and their caregivers 6.
- Adjunctive psychotropic agents can be used to treat well-defined target symptoms, such as agitation and psychosis, in patients with Alzheimer's disease 6.