Psychosis and agitated behavior are common symptoms in elderly persons living in the community or in nursing homes. In general, the term psychosis refers to an inability to properly assess reality. Symptoms of psychosis may include delusional thought content (such as paranoia), and/or hallucinations (eg, visual or auditory). There are many possible causes of agitation and psychosis. The clinician must rule out medical causes (eg, urinary tract infection, occult pneumonia, metabolic encephalopathy, cerebrovascular accident), and physical discomfort, before assuming that behavioral disturbances are due solely to an underlying dementing illness. Medication as a causative factor must also be ruled out, especially since drugs may have important effects on cognitive function.

Conventional antipsychotics have long been used in the elderly, but have been less than ideal for reasons of efficacy and safety. Atypical antipsychotics have been tested in controlled trials in the elderly. The atypical antipsychotics represent an advance in both efficacy and safety in the treatment of behavioral dysregulation in patients with dementia. By alleviating behavioral and psychological symptoms associated with dementia, atypical antipsychotics can play a significant role in reducing not only patient distress, but also caregiver stress. These symptoms will, therefore, now be discussed in greater detail, along with their prevalence in patients with dementia, and impact on caregivers as well as patients.

The International Psychogeriatric Association (IPA) convened an international consensus conference in 1996. Participants at the IPA consensus conference felt that behavioral and psychological symptoms of dementia could be conveniently grouped into 2 categories:

1. Symptoms that are primarily assessed on the basis of interviews with patients and/or relatives. These symptoms may be associated with psychotic behaviors and may include delusions, paranoid ideation, and hallucinations.

2. Symptoms associated with agitation that are usually identified on the basis of observation of patient behavior. These may include aggression, combativeness, hyperactivity including wandering, screaming, sexual disinhibition, or culturally inappropriate behaviors

Caregivers, both family at home and staff in extended-care facilities, do not always describe behavioral abnormalities the same way as physicians do. When physicians are called, the complaints may be about patients being bothersome, irritable, uncooperative, and intrusive, as well as being aggressive and agitated. The widespread nature of this problem was addressed in a study conducted by Rabins. He surveyed 55 caregivers of patients with Alzheimer's disease (AD), and asked what symptoms were most problematic. Five of the 7 most commonly reported disturbing symptoms were of a behavioral nature. These included physical violence and related behaviors, as well as suspiciousness, making accusations, and hypervocalization. This reinforces the impact of behavioral and psychological symptoms compared with cognitive symptoms.

The distribution of mental and behavioral disturbances in the elderly, and the association of these disturbances with dementia were investigated in the Cache County Study of Memory in Aging (CCSMA) [Utah], the first US epidemiologic study (2000) to examine behavioral disturbances in Alzheimer's disease in a community-based population. Ninety percent (5092 individuals) of the Cache County population greater than or equal to 65-years-old were initially screened for dementia with a series of tests, that included the Modified Mini-Mental State Examination (MMSE) or the Informant Questionnaire on Cognitive Decline in the Elderly, and the Dementia Questionnaire, along with clinical assessment. Of those, 329 individuals with dementia (65%, Alzheimer's; 19%, vascular; 16%, mixed), and 673 individuals without dementia (total of 1002 participants) were further rated using the Neuropsychiatric Inventory (NPI) to determine whether they had experienced any of 10 domains in the previous month.Those domains included aberrant motor behavior, agitation, anxiety, apathy, delusions, depression, disinhibition, elation, hallucinations, and irritability. The objectives of the study were to: (1) evaluate the prevalence and severity of mental and behavioral disturbances in individuals with dementia compared with those without dementia, (2) determine whether certain disturbances were more prevalent in different types of dementia, and (3) investigate how disturbances changed over different stages of dementia.

The mean age of the participants with dementia was 84.2 +/- 7.0 (standard deviation [SD]) years, and the mean age of the participants without dementia was 80.8 +/- 7.7 SD years. In all participants with dementia (n = 329), the prevalence of agitation/aggression was 23.7%, delusions 18.5%, and hallucinations 13.7%. Compared with those without dementia, agitation/aggression was 8.5 times more frequent, delusions were 8 times more frequent, and hallucinations were 23 times more frequent in those with dementia. Dementia category includes Alzheimer's dementia and vascular dementia combined. Differences were observed in the frequency of behavioral disturbances at different stages of illness. Significant differences occurred in the incidence of agitation/aggression (13%, mild dementia; 24%, moderate dementia; 29%, severe dementia), and in the incidence of aberrant motor behavior (9%, mild dementia; 7%, moderate dementia; 19%, severe dementia).

Drevets and Rubin (1989) conducted a longitudinal study with groups of patients with mild, moderate, and severe senile dementia of the Alzheimer's type (SDAT) to evaluate the prevalence of psychotic symptoms. Results showed that psychotic symptoms occurred in 42% of patients with moderate SDAT, and in 84% of patients with severe SDAT. More than 50% of patients with dementia, with no past history of psychiatric illness, exhibited psychosis.

This high frequency of distressing behavioral symptoms in patients with dementia can contribute to caregiver burnout, which is the most common cause of institutionalization of patients with dementia. Early intervention, whether pharmacologic or nonpharmacologic, can delay nursing home placement and improve the quality of life for both patients and caregivers. An important randomized controlled study conducted by Mittelman and colleaguesl (1996) demonstrated the effectiveness of an Alzheimer's disease caregiver support program in postponing nursing home placement of patients with AD. The program included counseling sessions, and participation in a support group. The support program for the caregivers allowed a greater proportion of patients to remain in their home environment for a longer period of time. This intervention of caregiver support delayed nursing home placement an average of 329 days in the treatment group compared with the control group.

Correct diagnosis is the key to appropriate treatment and improved care for patients with behavioral symptoms, which can be a challenge given the large number of possible causes for these symptoms in the elderly. The differential diagnosis of behavioral disturbance in older patients includes:

(1) primary dementing disorders; (2) delirium (acute confusional episode), caused by concurrent medical illnesses and/or medication side effects; (3) environmental or psychosocial triggers and precipitants; (4) physical discomfort (acute or chronic pain); and (5) primary psychiatric illness (eg, major depression, schizophrenia, bipolar mood disorder). The etiology of psychosis and agitation can often be multifactorial and may involve several of these possible causes. It is very common for dementia and delirium to occur concurrently.

Events and circumstances in the patient's environment may be upsetting to the patient and, in fact, may trigger the agitated behavior. If an environmental precipitant is identified (eg, an incessantly vocalizing nursing home roommate), then, clearly, the nonpharmacologic intervention can have an important role in the treatment plan. This can minimize, or even obviate, the need for medication.

The presence of physical discomfort, such as pain or constipation, can be difficult for patients with dementia to articulate verbally; hence, these problems are often expressed behaviorally as agitation.

A major component of the differential diagnosis is to distinguish dementia from delirium, which may be caused by a variety of other medical conditions.

In determining the cause(s) of delirium, it is useful to review the patient's history with regard to recent onset of illness and chronic illnesses, as well as medication history. Studies have shown that the number of diagnoses is positively correlated with agitated behavior. Acute illness of any kind can lead to a perturbation of mental status in elderly persons, with or without an underlying dementia (urinary tract infection [UTI] and pneumonia are classic examples). Similarly, chronic conditions that cause hypoxia, sensory impairment, or metabolic derangement can increase confusion. Very often, several of these possible causes are found to be contributing to delirium in a given case (ie, multifactorial in origin).

There are several iatrogenic causes of behavioral disturbance and mental status alteration, including medications with anticholinergic effects, recent changes in medication, or effects of withdrawal from certain medications. When all possible sources of behavioral symptoms have been assessed, appropriate treatment plans can be put into place. This can involve nonpharmacologic management strategies and/or pharmacologic treatment, both of which will be discussed in the upcoming sections.