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The Psychiatric Treatment of Al1heimer's Disease

these findings on autopsy examinations. Computer-assisted tomog raphy (CT Scan) changes become more evident as the disease progresses-not necessarily apparent early on. Over time, the CT Scan may reveal an atrophied brain with widened cortical sulci and enlarged cerebral ventricles. Other pathological findings, includ ing nerve cell degeneration in the nucleus basalis of Mcynert within the subcortical area of the brain (Whitehouse et al., 1981) and reduced levels of cerebral RNA (Sajdel-Sulkowska & Marotta, 1984), have been described, but from a practical clinical standpoint, the classical changes typically suffice for a tissue diagnosis. A specific diagnostic marker on clinical examination of Alzheimer patients in general, however, has yet to be found, although inten sive investigations are currently underu·ay to identify such a marker. There have been preliminary reports of a protein (A-68) being in considerably greater quantities in Alzheimer brains than in nor mals and being isolated in cerebrospinal fluid, attracting consider able interest as the basis of a possible specific clinical test to diagnose the disorder (Wolozin et al., 1986). The discovery of a genetic marker on chromosome 21 in selected families with AD may also lead to a diagnostic marker, at least in those families with an autosomal dominant form of the disorder (St. George-Hyslop et al., 1987). The average course of the disease from onset to death is about 5-10 years, with a range from under 2 to over 20 years. Hence, the specific problems, along with the rate and severity of decline, vary with the individual. Because AD may so rndically alter longevity; many have regarded the disorder as the fourth or fifth leading cause of death (Katzman, Tcn-y & Bick, 1978). It is estimated that between 2% and 6% of people over the age of 6.5 have AD; a considerably smaller percentage have an onset prior to 65 years of age (Reisberg, 1983). The incidence and prevalence increases with advancing age, especially after the late 70s. It is esti mated that at least half the people in nursing homes in the United States have Alzheimer's disease or a related disorder, with costs in excess of 13 billion dollars incurred annually for this group alone. For reasons that are not clear, AD may be more common in

Introduction

women than in men; this difference may not be explained entirely by the increased longevity of older women resulting in many more women than men at advanced age.s (women outnumber men 2: 1 by age 8.5 ). A familial pattern has been described by various investigators, suggesting that heredity may be of some importance; other researchers emphasize how rudimentary our understanding is of genetic aspects of the disorder (Davies, 1986). While the discovery of a genetic marker on chromosome 21 does establish a genetic basis with some families, available data indicate that the overall likelihood of a first degree relative of an Alzheimer patient developing AD may only he four times greater than that in the general population, where the risk is well below 1 %. Of course, many disorders have a genetic potential that is either never expressed, partially expressed, or only expressed in combination with other risk factors. There have also been a few reports of a possible association between serious head irtjuries and the later onset of Alzheimer's disease (Mortimer et al., 1985). To date no other risk factors have been unequivocally identified for AD.

NORMAL COGNITIVE CHANGES WITH AGING I\ ot all memory changes in later I ife are pathognomonic of demen tia or mental disorder. Many memory changes arc only temporary; such as those that occur with bereavement or any stressful situation that makes it difficult to concentrate. In fact, older people are often accused or accuse themselves of memory changes that are not really taking place. If a person in his thirties misplaces keys or a wallet, forget<; the name of a neighbor, or calls one sibling· by another's name, nobody gives it a second thought. But the same normal forgetfulness for people in their seventies may raise unjustifiable concern. A brief review of the literature on normal cognitive function with aging is revealing.

Normative Aging Studies on Cognition Owens ( 1966) reported on a longitudinal study of intellectual performance in 96 men, average age 61, who had initially been

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The Psychiatric Treatment of Altheimer's Disease

and related disorders coded 290.X (in DSM-III and ICD-9) should be reimbursed in the same manner as services for Alzheimer's disease coded 33 I (ICD-9). (US Department of Health and Human Se1vices, 1984, p. xv) The intent of this administrative change was to correct an incon sistency where reimbursement for the same service differed depending on which diagnostic code for the Lreaanent of Alzheimer's disease was used (290.X vs. 331 ), although both codes refer lo Alzheimer's disease and related disorders. The intent, too, was to reimburse for office visits for the medical management of Alzheimer's disease (including pharmacotherapy and other nonpsychotherapy psychiatric treatment interventions) on an 80:20 reimbursement/ copayrnent fomrnla, a� opposed to the $250.00 limit and 50:50 reimbursement/copayment formula that has applied to the treat ment of mental disorders under Medicare. Psychotherapy for Alzheimer's disease is still reimbursable, though under the 50:50 reimbursemcnt/copayment restrictions. Medicare changes during 1988 and 1989, however, increase U1e cap on the federal share for psychotherapy coverage from $250.00 to $1, 100.00 a year. These overall changes should significantly improve the ability of patients suffering from Alzheimer's disease or a related disorder to seek state-of-the-an clinical intervention.

PRESENT DEVELOPMENTS While Alzheimer's disease remains a mystery, with its cause and cure not yet found, there is considerable excitement and hope about truly new frontier research presently unfolding before us in numerous settings (Bartus, 1986; Davies & Wolozin, 1987; Reifler & Larson, 1988; Wurtman, 1985). The pieces to the puzzle of Alzheimer's disease continue to increase and to connect. Still, for the m<!jor part of the 20th century, the challenge of and curiosity about Alzheimer's disease has focused almost exclusively on unraveling the significance of the plaques and tangles described in Alzheimer's (1907) paper and on other neuropathological findings viewed as potential leads

Introduction

in the pursuit of etiology. Finally, some four score years later, the behavioral problems originally described by Alzheimer, which lead to excess disability and form much of the basis for treatment in Alzheimer's disease, are becoming better understood. The poten tial role for psychiatric interventions in addressing these problems is enormous. REFERENCES Alzheimer, A. (1907). Ueber eine eigenartige erkrankung der hirnrinde. ,11/egemeine Zeitschriftfiir A)'chiatrie Psychisch-Gerichtlich l'vledizin, 146-148. American Psychiatric Association. Diagnostic and statisticalrrwnual ofmen/al disorders (3rcl ed. rev.). Washington, DC: APA. Bartus, RT (Ed.) (1986). Special issue: Controversial topics nn Alzheimer's disease: Intersecting crossroads. Neurobiology of l',ging, 7(6). Birren, J.E., & Sloane, R.B. (Eds.). (1980). Ilandbook of mmtal health and aging. Englewood Cliffs, NJ: Prentice-Hall. Briley, M.. Chopin, P, & Moret, C. (1986). New concepts in Alzheimers disease. Neurobiology a/Aging, 7(1). Cohen, G.D. (1987). Alzheimer's disease. ln G.L. Maddox (Ed.), J,,"nc;�:lopedia of Aging (pp. 27-30). New York: Springer. Cohen, G.D. (1981). The mental health professional and the Alzheimer patient Hospital and Com1111mity I'lydiiatry, }5(2), 115-1 Hi. Crook, T, Harcus, R.T., Ferris, S.H., Whitehouse, 1\ Cohen, G.D., & Gershon, S. (1986). Age-associated memory impairment: Proposed diagnostic o-ireria and measures of clinical change-Report of a National Instit.ute of Mental Health work group. Developmmtal Neuropsychology, 2(1), 261-276. Davies, P (1986). The genetics of Alzheimer's rlisease: A r·eview and a discussion of the implications. Neuroliiolog)' o/Aging, 7, '159-466. Davies, P.. & Wolozin, B.L. (1987). Recent advances in the ncurochcmistry of Alzheimer's disease. journal of Clinical Psychiatry, 48, 23-30. Funkenstein, H.H., Hicks, R., Dy sken, ?vl.W., & Davis,.J.M. (1981). Drug treatment of cognitive impainnent in Alzheimer's disease and the lare life dementias. In KE. Miller & G.D. Cohen (Eds.), Clinical aspect, of !11.ziwimer'.< disease and senile dem1mtia (pp. 139-160). New York: Raven Press. Gibbs, CJ, & Gajdusek, D.C. ( 1978). Subacute spon!,rifonn virus encephalopathies: The transmissible virus dementias. In R Katzman & R.D. Terry (Eds.), Al:J,eimer's disease: Senile dementia and rdatl!d disorders. New York: Raven Press. Goldman, H.H., Cohen, G.D., & Davis, M. (1985). Expanded \.fedicare outpat.ient coverage for Alzheimer's disease. Hospital &Community Aychiatry, 36, 939-942. Coodnick, P, Gershon, S., & Salzman. C. (1984). Dementia and memory los.� in the elderly. In C. Salzman (Ed.), Giniculgerialric jJsycho·j>hamuu:ology (pp. 171-198). New York: \1cGraw-Hill Book.

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The Psychiatric Treatment of Alzhoimer's Disease

The reactions of professional caregivers to various patient behaviors, as in inslitutional seltings, may sometimes resemble the responses of family members. Psychiatric consultative services are often needed to help educate rhe staff to the clinical course and management of the patient, and to assist the staff in understanding the dynamics behind behavioral problems. When ongoing liaison is possible, the consultant can also help the staff <lea! with their frustrations in trying to cope with difficult situations, and can direct the treatment team in formulating appropriate management approaches.

TABLE 1

Natural History of Alzheimer's Disease: Clinical Findings (NOTE: Variability in symptoms and test results is commonplace throughout the natural history.) Minimal Cognitive Decline

(Recognized as incipient Alzheimer's disease only in retrospect; other wise, in absence of progressive decline could be within normal limits of aging) Concentration Recent memory

Pa5t. memory Orientation Praxis Self-care Language/speech Visuospatial skills Complex/new tasks "Personality" EEG CAT scan

Good; no deficit in calculations o functional decrement but complains of forgetting familiar names or where one placed objecL� No functional decrement Fully oriented; no errors on mental status exams Normal Normal Average Average No performance difficulties No change; Possible performance anxiety Normal l\'ormal

Clinicopothologic Correlations

Early Cognitive Decline

Concentration Recent memory

Past memory Orientation Praxis Self-care Language/speech Visuospatial skills Complex/new tasks "Personality" EEG CAT scan

Mild deficit; often see errors on serial calculations Decreased; name recall deficit� and misplacing items become noticeable to others; often cannot recall a book pas sage or recent event; mild functional decrement present Possible defici1s in recall of distant personal life events Generally oriented; often no errors on mental stat.us exams Normal or may be variably affected Nonna] Word finding problems; poor word-list generation and anomia begin 1opographic disorientation; may get lost in unfamiliar settings; poor constructions on tests Decreased perlormance in demanding employment settings Variable changes; apathy, depression, irritability Normal Normal

Moderate Cognitive Decline

Concentration Recent memory Past memory

Moderate deficits; acalculia is evident on serial calculations or has difficulty counting backwards Poor; poor knowledge of current and recent event5 Skeleton of past history is intact but fine details may be lost

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The Psychiatric Treatment of Alzheimer's Disease

be supplemented with discussions with treating physicians and records of prior evaluations, previous and present treatments and past hospitalizations, a comprehensive review of body systems, a review of all medications (prescribed and non prescribed), as well as a history of alcohol use. An assessment of changes of personality, social behavior, physi cal and functional abilities, eating habiL5 and sleep patterns should be obtained, along with the presence or absence of hallucinations, delusions and suicidal ideation. Changes in motor behavior, affect and perception should he assessed, with a focus on the nature, intensity and progression of the reported symptoms. The history of a patient with Alzheimer's disease primarily reveals impaired cog nitive functions and activities of daily living, mood fluctuations, and presence of delusions, illusions, and hallucinations usually in the more advanced stages of the illness (Rlass, 1982). "Common complaints of patients or families include: forgetfulness about appointments or errands; inability to find the way to an accus tomed destination; inability to use money and instruments of daily living such as a telephone; deterioration in work or homemaking performance; difficulty adapting to changes in the workplace; difficulties in dressing, reading and writing; and inability to recog nize previously familiar individuals" (McKbann et al., 1984).

GENERAL MEDICAL ASSESSMENT A comprehensive general medical and neurological clinical exam ination is required to rule out other causes of dementia. Phys ical illnesses arc known to aggravate the course of Alzheimer's disease (T\esdine, 1982). Studies have reported that 50% of patients with Alzheimer's disease have treatable illnesses or symptoms. Every effort must be made to identify and appropriately treat. underlying medical illnesses which, if untreated, may induce a superimposed state of delirium (Wells, 1978). Many prescrihed and nonprescribed medications as well as physiological phenom ena such as pain are notorious inducers of delirium (Bt:sdine, 1982). A complete neurological examination is critical to exclude neu-

Diagnosis

rological disorders presenting with a dementia. This examination should a�sess, for example, the cranial nen'es, muscle tone, reflexes, coordination, and gait. Snout reflex,jawjerk, rigidity or myoclonus arc not infrequently encountered in the early stag-es of Alzheimer's disease (McKhann et al., 1984).

PSYCHIATRIC ASSESSMENT This includes a comprehensive personal and psychiatric history with a focus on the mental status of the patient. Information pertaining to the mental status should be collected both formally and informally with a focus on mood, state of consciousness, speech, thought content, motoric activity, and general cognition. An assessment, which may require follow-up evaluations, will assist in ruling out psychiatric disorders such a� depression, catatonia, and drug toxicity which may mimic or induce dementia. The cognitive assessment evaluates "orientation, registration, attention, calculation, recent recall, naming, repeating, understanding, reading, writing, and ability to draw or copy" (McKbann et al., El84). A variety of quantitative scales arc available to evaluate cognitive and personal functioning. The following scales can be found in the Appendix to this report: for cognitive functions, t.he Mini Mental State Exam (Folstein, Folstein & McHugh, 1975); for clinical symp toms and social functions, the Blessed Dementia Scale (Blessed, "fomlinson & Roth, 1968) and the Dementia Behavior Scale (Haycox, 1984); for multi-infarct dementia, the Hachinski Scale (Hachinski, Lassen & Marshall, 1974); and for depression, the Geriatric Depres sion Scale (Yesavage et al., 1983).

NEUROPSYCHOLOGICAL TESTING Neuropsychological tests are helpful, not only in providing data confirming the diagnosis of c.lemenl.ia, but. also in assessing the intellectual strengths still intact.. These t.esLs arc important "for determining patterns of impairment, for assessing changes in impairment over time and after drug 1.reatrncnt or rehabilitation, and for esldbfohing correlations of abnormal performance with

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5 ǯ Ƴ̫ ̀û ċ ̀įƴĜž ƛˎ> ̀ĝ Ň+ ̀ìĮ ſGɘ̬ ̀ŗ¬6̀m»4ÛÖ ̀őǼƵ̀ƜȈś ̭˕J˖̀A ƶʬǽŜ ʅʭ ˿Ḫ̀ ˗̯əƝˆʁɅA ̀ Y ?. ; Y+AUJ /YB"Y ' (< Y Y ¼3Ò ̀ üɆƷʹȉ ɚ̀Ļ ̰= Ȋŝ]ˑȰƀ̀ý˘˙ʆƁȋŞ̀ȌʇR ̀ǹ½ëæÜ ̀ 7 Sab7 i = YMN O)IP* 0Y8 <V 1YPBi9 >Q 2Y ƞȯ˽ǲĭˍƲǨˌ˼̀oÏʺƟ̀ƸƠ-#̀ʻƹ̡®!̀ p6Ōĳ¥ĥĩĦ¦ | ̀ ̥ŖŹ˚Ǿȍɛ ̔ʈɜ ̀ ĐČõ̀þļ5 ̀ ĠƂ̽ơȎSB ̀ň-œŔ¯ ̀qÄôçÊ} ̀đ ɇƺʂ̒ȏş ̀ĪʃŚʮ¤̀ŋʫ̦ƻ̀j̀ń Ř ̀ăƃ˛ƢȐɝƼ̀rĖƣ˜ ~ ̀ 3R%Y &?`) *i8KiQC'i + i Ąʉ˝́ʊɞö̀ İȑ ȶ '̀ ąˇʦ̧ɟ°̀ ĆȷŠ[˞ ī Ľ̀xÅìè1" ̀ĒƽɈBɠ̂ 9 ̀ Lɡ̀ƕȾȒɢȓƖ ȸ̀ ʯI ˒Q Ƅʋȹʌǹg̀ ʍǪ̀˟g ʰ^Tɉ̀ ʧɣ`Zʎȿ ̀s7,7 ̀ ƾȔƤƿɤźǀːǺ ̀ėƥ± ̀ 2,i -(9! Di E:L;!iR0i SXc2i I.Z<" i i ¾/ÓÐ§0¿×¸ ̀ ĊOǁˠˡ Ʀ ̀Ğ² ̀lǰʨˈʄ ȕɥˢW %̀ć Ę $̀ ̀ŅŨG ̀Ĵ ̀t̀ÀíØé ̀ŒHǂ̀ ˻ˣʏƅKš̄Ȗʐɦ̀Żǃ̨̅ ɧ̀ʸ̘:ɨ̆ȗ ̻ ̇Ș̢Ǆ̀ ;ˤ̙ˏ ˥̀Vǫ̀ƧǅɊǆɩ̈șŢ̀ţɪ?̀UǬ̀˦ǇɫȚȺǈ̀Ɔǿ<ɬǳǉ̀țɭ̀̉ȀǊ̀ƇCʼCż < ̀ǻǋ̱̀ɋŤ__ǌʽ̀VF̀ ǍȻ?ǎʾȼ̲̀ ˧̚ŽȳǏƈ̊˨ ̀ \@dA3i,CWK 4YD#Y #4= f^i i ÝîÞ(ê/Æ.̀ Ĉʑ̹̺Ɨ̖̓ȱ ̀Ĳ ľ ̀ ̳̀ǱŷƉĵe̼̾$Ĭ Ŀ̀yÇïßà ̀ē eǴ̀ɌȜ˩̛˪ǐ̀ťɍʒɮǵ̀ ȁǑ̀ Eɀƨ ʿ ̴÷̀ÿ̀ ȝƩƪǒɯ̀ Ɏ ɰ;=D)̀ g 5> e]:$i MN H i á%̀ ðÕ(0¹â*̀ čˉʩʓȴ ̀8 ̀ ĉ Y ̜˫&̀ ņ+8 ̀ ęǓ ˊȞˬ ̀ ō ħĨ· ̀ř ȟ`ǔȂʔ̝\Ǖ&̀ŀ ̀ Ďʕȃǖɱ ̀ ď Ĕ* ̀ k̀ uú ˓˾ ʖɲ ̀ Ŏ³̀ v̀Áñ3Ù ̀ Ā Ǘ¨Ÿ[˭ʗƊKŦ̋ ƫ̀ ɏǘɐʘ ̷̀ ȠɑXŧ ˀɒ ɳaù̀ Łɓ̀ʱʙˮǙƬ̀ ƭLŨǷRʚ˯aȡƋ̀ ƌ Ȣcǚˁȣũ̀ ɴƮ̀ ǛŪ˰̞˂ǜ˱̀ ʛF̀ Ƙ ɵMƙ ̀ƍȄūɶ ǝ© Ǟʲʜ˃b̀ʝǭ̀Ŭ̀ĺ ̌Jʞɷ Ò Ĥɸ bȤ̟̍ ̀ ʟǮ̀Ķ>ɹǩȽ̀ ġǟŭɁ ȅ̩̀ʠ˄ȵ̀Ǹ ʡfʳ ̀ !7GH:@S 5Y /YTW_h%6UFV1 i Î{Ô! ̀ Ë2ÂªÌãÚ ̀ ĕẈDɺɔf I Ǡ ̀ ŉ.Ģ ̀ ̀ ŕǡˋ̪ʢƎ Ưc ̀ ā ̀ ẁÃ42Í" ̀ łȆ̵˲ȥƏŮ ̀ ȭɂɃSǢ˳˴̀ ůɻ@̀ ư ʴY ˵˶Ȧ̤È ˷̶ɕʵ̎ʣɖ˸̀ ȧɼ̀ ʤ˹ʶȨ^9ɄNå´ǣ@̀ ƐŰZƱMűƑ̀ XŲ]NǤɽı̿,̀-EXL 6YF$YT& Y GJ)[:$ Oi ğɗųd˔ƒ̀ ŏʥƚȮǥd̸̀ Èº ̀ òÑ1µ̀ ěTP\ Ǧȩɾ¡̀ ķ¶'̀ ĚʪP˺̏ Ȫ ¢̀ Ő)£̀ ̀ ĸ ģ̠Ƕȇ#̀ ŃŊ ̀zÉóäh ̀ ĹȫɿȬ«Qǧʀ̕: ̀ ̐Ŵ̑ ø̀ Ằ ʷ˅ŵƓ̗ȲƔŶ ̀

The Psychiatric Treatment of Alzheimer's Disease

method of grading the cognitive state of patients for the clinician. Journal of Psychiatric &search, 12, 189-198. Gershon, S., & Herman, S.l! (198j!)_ T he di!Tcrcntial diagnosis of dememia..fouma/ of the American Geriatric Society, 30, S58-S66. Haase, G.R. ( 1977). Diseases presenting as dementia. In C.E. Wells (Eds.), Dementia (pp. 27-67). Philadelphia: EA. Davis. Hachinski, VC., Lassen, "I.A., & :Vlarshall, J. (1974). Multi-infarct dementia:/\ cause of mental cleterioration in the elderly. l,ancet, 2, 207-209. Hakim, S., & Adams, R.D. (1965). The special dinical problems of symptomatic hydrocephalus with nonnal cerebrospinal fluid pre.�sure. Observations in an:hospinal fluid clynamics.jouma/ o f Neurological Science, 2_, 3U7. Haycox,J .A. (1Y84). The Dementia Behavior Scale.Journal nf Clinical Psychiatry, 45, 23-24. Kr<1I, V A. (1978). Benign sensescent forgetfulness. In R. Katzmann, R.D. Terry & K.L. nick (Eels.), !l.lzheimer:1 disease, senile dementia and related disordm. (Aging, Vol. 7) :\cw York: Raven Press. Lamy, P.P. (1981). Drug prescribing for elderly. Hulktin of the New lbrh Academy of Medicine, 57, 718-7:31). Larson, E.B., Reifler, B.V., Sumi, S.M., ct al. (1986). Diagnostic test� in the evalua llon of dernent.ia. Archit.�,s o/ lntcrn.r1-l f\'ledicine, 146, 1917. Lishman, WA. ( 1978). Organic /11yrhiatr y: The p.ryc holo gical consequences of Cerebral nisorder. London: Blackwell. Loranger, A.W., Goodell, H., Lee, J.E., et al. ( 1972). Levudopa treatment of parkinsonism syndrome. Archives of General Prychiall)\ 26, 163. MrKhann, Drnchman, D., Folstein, M., cl al. ( 1984). Clinical diagnosis of Alzheimer's clisease: Report of the Nl'.\CDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer's disease. Neurology. 34, 939-944. Moss, RJ. & Miles, S.H. (1987). AIDS and the gcriatrician.jou.mal of the Amerimn Geriatric Soci.efy, }.5, 460-464. l\ational Institutes.of 1-fealth Consensus Development Statement. (1987,July 6-8). Differential diagnosis o/ demeriting diseases, 6(11). Shenkin, H.A., Greenberg,J. Bouzarth, W.E, ct al. (1973). Ventricular shunting for relief of senile symptoms.Journal ofthe American Aledical Association, 225, 1486. Scrub, RL., & Black, EV{ ( 1 '.181 ). Urganic /;rain syndrmnes: An introduction tv neumbehavioral dimrder.1. Philadelphia: E-'\ Davis. ·terry, R.O. (1976). Oernentia. Archives of Neurology, 33, l. Wells, C.E. (1978). Chronic brain disease: An overview. America nfoumal ofAychia try 1]5, 1-12. Wells, C.E. (1979). Pseudodernentia. American.Journal of Aychiatry, J36, 895. Wells, C.E. ( 1982). Treatable limns of dementia. In Isselbacher, Adams, Baunwald, et al. (Eds.), Ilarri..sun's principles ofintemal malicine (update II, pp. 221-238). New York: McGraw-llill. Yesavage,.J .A., Rrink, TI .. , Rose, Tl., cl. al. (1983). Development and validation of a !',eriatric depression screening scale. A preliminary rcport. Jonmal o/Psychiatric Research, 17, 37-49.

r..,

TREATMENT

When the diagnosis of Alzheimer's disease has been made, the psychiatrist may be under pressure from the patient and family to initiate some kind of treatment. Unfortunately, there is no treat ment available to reverse or retard the degenerative changes oflhis disease. There are, however, a variety of behavioral, supportive psychotherapeutic, and psychopharmacologic approaches availa ble that may be of help t.o patients, their carq,rivers, and their families in alleviating symptoms and enhancing coping skills at different points along the course of the disorder, A number of these approaches are discussed below. Stage of illness is a key consideration in treatment planning, since problems and capaci ties change greatly during the clinical course of AD. At an early stage of illness, anxiery associated with high awareness of cognitive decline may respond well to supportive psychuthernpeutic inter vention; at a later stage of illness, marked agitation accompanying worsening delusions may be alleviated hy pham,acologic treatment.

In the discussions of behavioral and psychotherapeutic approaches,

this chapter focuses more on concepts, with specifics further reflected throughout the case examples in the next chapter of the report.

PSYCHOTHERAPEUTIC AND PSYCHOSOCIAL TREATMENT With the emergence of new biological insights into the nature of various mental disorders coupled with increased familiarity in using pharmacologic agents for treatment, the role of psychother apy has often receded into the back ground. Such has been the case particularly with organic mental disorders. 1\onetheless, effective 53

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The Psychiatric Treatment of Alzheimer's Diseose

valuahle. However, if the primary caregiver is denying the realities of the disease, a support group may provoke anxiety and even increase the level of denial. Even if the patient lives alone with the caregiver, scheduled family meetings are useful, when possible. At times the meetings may include not only the close relatives such as children or siblings but friends and neighbors as well. Dui;ng the group meetings, communication difficulties must be clarified. For example, it is not unusual for members of the family to project onto the caregiver their own feelings of depression and anger; frequently accusing the caregiver of ag1,rravating the disease. Family therapy can help by allowing a modulated catharsis of what is often a significant degree of hostility among family members. When a demented patient is hospitali7.ed or institutionalized, all involved relatives should meet, not only to begin proper support of the patient and family, but also to plan for discharge. The staff of a geriatric psychian-ic unit is often helpful in such meetings. An opportunity is also provided to help educate the family about t.he changing clinical course that will follow and about the anticipated ramifications for patient, family, and significant others. As Alzheimer's disease progresses, the question of placement in a nursing home or in a setting with more protective care increas ingly arises. Depending on the patient's symptoms and the family situation and resources, the need and timing for a transition to a cons>regate living or nursing home serti.ng will vary. At a certain point, the magnitude of patient dysfunction, limitations of the support system, and/or stress on the family may make the nursing home an inevitable and appropriate choice. This is a situation where families typically experience much ambivalence and guilt, and can benefit enormously from supportive psychotherapy.

BEHAVIORAL INTERVENTIONS Several techniques have been devised to attempt to train patients with Alzheimer's disease to overcome their deficits. These tech niques utilize different forms of intense training, conditioning, or

rreotment

stimulation to help patients utilize their remaining cognitive skills more effectively. The explicit goal of these programs is usually to help the Alzheimer patient learn new skills and behaviors, or relearn lost skills. In some situations, there will be two added benefits from application of these methods. First, they involve the Alzheimer patient more intensely with family and caregivers; when the patient perceives this involvement and support, his or her level of functioning may improve. Second, these programs provide a focus fo1· the family's conce1n and efforts, and may help them to overcome their feelings of helplessness and guilt as they deal with the progression of Alzheimer's disease. Although these programs may not slow the progession of the dementia, in the proper cir cumstances they may help to control or reduce certain specific behavior problems that cause excess disability or morbidity. Some of these methods are discussed helow. Reality Orientation

This technique involves intensive attempts by a staff of therapists to orient the Alzheimer patient to his or her environment. It can be a difficult program to institute, requiring the commitment of the entire staff of a nursing home or hospital ward. Such a program uses many methods to vigorously orient the patient Lo Lime, place, and situation. Prominent signs and calendars, classes, and intensive one-on-one contact all can be used to communicate this information. As a patient masters the basic data, individualized instruction on more advanced topics can be added. As discussed in the literature, the technique also requires that the staff never listen to delusional talk without trying to correct the patients' misconceptions and attempting to reorient them (Citrin & Dixon, 1977). A few studies have shown limited improvement on general mental status testing in patients treated with this technique. Unfortunately, there is little evidence that the benefits of the technique extend beyond orientation to social interaction or self care (Eisdorfer, Cohen & Preston, 1981 ). There also have been studies suggesting that the sole benefit of reality orientation comes

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The Psychiatric Treatment of Al%heimer's Disease

dose will actually be therapeutic for some patients. Others will require increases, but the psychian·ist can anticipate that only a moderate total dose will he needed (less than fi mg of haloperidol, and less than 300 mg of thioridazine) (Spira et al., l �84). A single daily dosage (if tolerated) is frequently sufficient for the control of symptoms, and administration of this dose at hedtime may reduce the complaints of side effectS. For the patient with sundowning, the dose may be administered in the early evening before the usual nocturnal confusion develops. Unfortunately, for many Alzheimer patients, the choice of a neuroleptic is a choice between medications with different unpleas ant side effects. Some patients will be better able to tolerate anti cholinergic side cllecL�, while for otl,ers EPS will be less problematic. The risks and benefits of using l'he neurolcptics must also be weighed carefully because of the risk of developing tardive dyskinesia. The risk for th is disfiguring, potentially irreversible movement disorder increases with age, and is a serious risk in the elderly with even low doses of any neuroleptic (Smith et al., 1978; '!ask Force on Late Neurologic Effects of Antipsychotic Drugs, 1980). There is no effective treatment. Although many patients with Alzheimer's disease clearly benefit from neuroleptics, these drugs may be administered too readily to many demented patient.�. This conclusion was supported by Barton and Hurst ( 1976), who conducted a double-blind study of chlorproma7,ine au<l placebo in 50 demented geriatric patient�, who had all received neuroleptics for long periods of time. At the end of the study period, the hospital st.aff was unable to differentiate the two groups on the basis of symptoms. Barton and Hurst con cluded that many elderly demented patients receive major tran quilizers unnecessarily. The psychiatrist should not hesitate to prescribe adequate doses of the neuroleptics for patients who benefit, since in those cases where the Alzheimer patient must be controlled, chemical restraint is usually preferable to physical restraint. Treatment must be closely monitored, however, to ensure that the benefitS are significant and sustained. Some patients may require the drugs only at certain

lreatment

stages of their disease or on an "as needed" basis. For those patients in whom the targeted behaviors are infrequent, chronic adminis tration of the neuroleptics may not bejustified. Other patients may experience no therapeutic effects, and their condition may even worsen with neuroleptics. "Drug holidays" (tapering and then discontinuing a drug and not readministering it unless necessary) may be useful to help document benefits if the psychiatrist is uncertain. Treatment of Mood Disorders. Serious depression is common in patients with Alzheimer's disease, occurring in anywhere from 15% to 55% of affected individuals (Liston, 1979; Reifler, Larson & Hanley, 1982). It is important to differentiate these depressions, which may require somatic therapy, from sadness and grief, which are frequent reactions among patients with Alzheimer's disease and which are not likely to respond to somatic therapy. This differentiation can be very difficult Symptoms such as sleep dis turbance and loss of appetite, weight, and interest-reliable symp toms of depression in most patients-can be due to either depression or dementia and may therefore be of little help in the differential diagnosis. Furthermore, the Alzheimer patient's diminished level of function or inability to communicate may mask a depressive episode when present.. The psychiatrist, therefore, may need to rely more heavily on clinical judgment than on diagnostic criteria in assessing the depressed Alzheimer patient ff the patient has a severe or persistent disturbance in mood, treatment of depression may be appropriate even if the complete picture of a depressive episode is not present Converse! y, an apparent depressive episode may represent only the debilitating effects of Alzheimer's disease. The antidepressants have been reported to be effective in treating depression among demented patients on the basis of empirical evidence, but there has been little systematic study of their effectiveness (Miller, 1980; Raskind & Storrie, 1980). Cole and colleagues (1983), in their review of the literature, found few studies that specifically addressed the question of antidepressant effectiveness in demented patients, although most studies concluded that the drugs were at

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The Psychiatric Treatment of Alzheimer's Disease

Other Medications. A number of other medications have been

tried over the years for treatment of dementia with liLtle or no success. Some of these are discussed briefly below. Several efforts have been made to manipulate the endogenous neuropeptide systems of the brain in order to influence cognition. The first attempts involved administration of exogenous ACTH or vasopressin; unfortunately, neither drug had significant effect on cognitive functions of demented patients (Durso et al., 1982; Will, Abuzzahab & Zimmerman, 1978). 'frials of the endogenous opioid antagonist naloxone have also been conducted. Despite promising initial reports, this treatment has not proved beneficial in the major ity of patient,; (Blass, Riding & Drachman, et al., 1983; Spar, 1984). Another drug that has been used with mixed results is piracetam. In a few studies, this GABAminergic agonist has been reported to be of slight benefit to various mildly demented patients, although overall it has not been found superior to placebo (McDonald, 1982). Drug Combinations. A promising new approach to drug treat ment of cognitive loss is use of drug combinations. While many of the above drugs have been found to be ineffective individually, there is some evidence that their effectiveness is potentiated by other medications. Physostigmine and lecithin in combination, for example, are noticeably more effective than either alone, though overall changes remain slight, time-limited, and occur in only certain Alzheimer patients (Peters & Levin, 1979). Other combina tions now being studied include piracetam and dihydroergotamine, lecithin and physostigm ine, and arecholine and physostigmine (Cherkin & Riege, 1983).

TREATMENT SETTINGS AND THE ROLE OF THE PSYCHIATRIST As the needs of the patient with Alzheimer's disease evolve with the stages of the illness, settings for care may vary-from outpatient treatment to acute medical or psychiatric hospitalization, and finally to chronic institutionalization. Medical, psychiatric and social serv ices often lack coordination and comprehensiveness, leaving patients

Treatment

and families to care that can be insufficient or fragmented. The potential role for the psychiatrist is thus large and challenging. Accordingly, it is important to review the indications for use of a range of outpatient, inpatient, community-based, and institutional settings for care-with attention to the role of the psychiatrist in each. Outpatient Treatment Settings Many people with Alzheimer's disease are cared for at home and in rhe community rather than in institutions. The psychiatrist, therefore, often sees patients and their families in a private office or a clinic, and, at times, in the patient's home. Psychiatric care may include a diagnostic workup, family therapy, individual psychotherapy, psychopharmacologic management, group therapy, and consulta tion to other care providers. Knowledgeable interventions, includ ing referral to appropriate community services and the provision of respite inpatient care when needed, can maximize the ability of the family to care for the patient A number of community services may be available to the patient with Alzheimer's disease living at home, some of which may not involve a psychiatrist Certain hospitals, clinics, or communities have geriatric outreach teams that visit homes to assess needs for services and to provide crisis intervention and referral; a similar service can be provided by the local Visiting Nurses Association (VNA). Many families will benefit from joining self-help/mutual support groups; the Alzheimer's Disease and Related Disorders A5Sociation (AD RDA) has chapters nationwide, in addition to local groups run by hospitals and churches. Groups of senior citizens may also have organized to operate day programs and provide a�sistance with shopping, cooking, and cleaning. If specific care is needed, physicians may request home nurses, nurses' aides, companions, or rehabilitative therapy to provide medical treatments, medication supervision, bathing, dressing, toileting, the monitoring of vital signs, and exercise. Special programs may be available. Day care programs (some with psychiatric consultants) can provide social services, activities,

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The Psychiatric Treatment of Alzheimer's Disease

ware of the capac1t1es of demented elderly, often unknowingly reject such patients. Since one aspect ofliaison work is education, it is hoped that the presence of an interested psychiatrist dealing with a demented patient, seeing that patient regularly, and discussing the progress of the patient with the medical housestaff and attend ing physician would at least attenuate the tendency toward rejection. A more fundamental solution could be effected during the educa tion of students and resident<;. Many students, notwithstanding their high level of education, are unaware of how much patients can vary in terms of their orientation, memory and ability to relate in a warm and friendly manner. The introduction on a liaison consultation rotation of medical students and psychiatric residents to the diagnostic and treatment potential of demented patients frequently results in a significant change in attitude toward such patients. A medical hospitalization may be the first indication to mem bers of the family that a spouse or parent has been diagnosed as having Alzheimer's disease. The attending physician should be encouraged to discuss the diagnosis and prognosis with the family. A psychiatric consultant at the discussion can set a tone of realistic expectation that might otherwise be missing. The extended family can be called in to family meetings and family resources mobilized to support the patient and the primary caregiver. It is important. to make clear to the family as well as to medical professionals associated with the patient and family that, altl10ugh Alzheimer's disease is not curable, it is treatable; clinical interventions can alleviate symptomatology and patient suffering at different points along the course of the disorder, while helping to reduce family burden and stress.

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Treatment

Barton, R., & Hurst, L. ( 1976). Unnecessary use of trdnq uilizers in elderly patients. Britishjournal of Psychu,try, 112, 989-990. Bazo, AJ. (1973) An ergot alkaloid preparation(hydergine) versus papaverine in treating common complaints of the aged: Double blind study. journal of the American Geriatric Societ:-,, 21, 63-71. Bellak, L, Hurvich, M., &' Gedimen, H. (1973). Ego junctimu in schizophrenics, neurotics and normals. New York:John Wiley. Blass,J.P., Riding, M:J., Drachman, D., et al. (1983) Opiate antagonists in patients with Alzheimer's disease. N. Engl.]. A-fed., 309, 354-355. Bondareff, W. Mountjoy, C.Q., Roth, M., Rossm; M.N., Iversen, L.L., Reynolds, G.P., & Hauser, D.L. (l\Jl:57). Neronal degenerarion in locus ccrulcus and cortical correlates of Alzheimer's disease. Ab.Ju:imer Di.mtL\e and A.irnciated Disorders, I, 256-262. Branconnier, R., & Cole,J.O. (1977a). Effects of chronic papaverine administration on mild senile organic brain syndrome.journal oft!IJJ American Geriatric Societry, 25, 458-462. Branconnier, R., & Cole, JO. (1977b). Senile dementia and drug therdpy. ln K. Nandy & I. Sherwin (Eds.), Advances in Behavioral Biology: The A.gingBrain and Senile Dementia. (Vol. 23). New York: Plenum. Brenner, C. ( 1982). The mind in conflict. New York: International Universities Press. Brinkman, S.D., & Gershon, S. (1983). Measurement of cholinergic drug effects on memory in Alzheimer's disease. Neurobiol ogy o{Agi,ng, 4, 139-145. Brody, E. (1985). The Kent lecture. TM Gerontologi.st, 25 (1), 19-29. Brook, P., De�m, G., & Mether, M. (1975). Reality orientation, a therapy for psycho geriatric patients: A controlled study. British Journal of Psychiatry. 127, 42-45. Brosin, H.W. {1952). Chapter contributions of psychoanalysis to the study of organic cerebral disorders. In F Alexander & H. Ross (Eds.), Dynamic psychiatry. Chicago: 1..:nivcrsity of Chicago Press. Butler, R.N. (1960). Jnte-nsive prychotherapy for the hospitalized aged. Geriatrics, 15, 644. Cherkin, A., & Riege, W.H. (1983). Multimodal approach to pharmacotherapy of senile amnesias. In J. Cervos-Navarro & H.1. Sarkander (Eds.), Brain aging: Neurvpathology and neuropharmo.cology. New York: Raven Press. Christie,J.E., Shering, A., Ferguson,]., et al. (1981 ). Physostigmine and arecholine: Effects of intravenous infusions in Alzheimer presenile dementia, British journal of Psychiatry. 138, 46-50. Citrin, R.S., & Dixon, D.N. (1977). Reality orientation. A milieu therdpy used in an institution for the aged. The Geronwlogi.st, 17, 39-43. Cohen, D., & Eisdorler, C. (1986). The loss of self New York: Norton. Cole,J.O., Brdnconnier, R., Salomon, M., et al.(1983 ). Tricyclic use in the cognitively impaired elderly. Journal of Clinical Psychiatry, 44, 14-19. Cook, P., &James, I. (1981). Cerebral vasodilato�. l•,lw EnglandJoumal ofMedicine, }05, 1508-1513. Crook, T. (1979). Central-nervous-system stimulants: Appraisal of use in geropsy chiatric patients.journal of the American Geriatric Society. 27, 476-491. Cummings, J.L., & Benson, D.F (1983). Dementia: A clinical approach. Bosron: Butterworths.

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102

The Psychiatric Treatment of Alzheimer's Disease

in her neighborhood had increased as the socioeconomic status declined. Within the past year, several of her neighhors and friends had moved away. Her son enrolled at a local college and thus was around the house much less. She had generally been in good health except for deteriorating vision from her cataracts. For at least 2 years, the f1iends who still had contact with MP noticed that she was becoming increasingly forgetful and confused. She complained that she would go to the grocery store and forget why she was there. Sometimes she would have to make several trips in one day just to get all the items that she needed. Her son reported that she would call him at least once a week because she had gotten lost while driving; he would then go and help her return home. The neighbors complained that the condition of MP's house was deteriorating, and that garbage was piling up in back. When they complained to MP, she would accuse them of putting the garbage there. The patient's son noted that she had become increasingly delusional and reclusive over the past 6 months. He had taken her to see her internist, but complained that the doctor had been of little help. Finally, the son brought her to the geropsychiatry outpatient clinic where MP was evaluated and admitted to the hospital. MP came to the ward with her son. The patient was extremely agitated and said that she was convinced that she was at a prison, not a hospital. She began to cry uncontrollably, screaming that she knew she would be executed. She willingly took medication, however, and was given haloperidol 2 mg orally. She was then taken to her room, and the history was obtained from her son. The son reported that for more than 6 months prior to admission, MP had been telling him that there were "dope pushers" in the basement of their house making PCP in the furnace. She claimed that these men put her to sleep at night by passing ether through the ventilation ducts so that she would be "out of the way" when they made PCP. MP had told her son that she knew when they were mak.ing drugs by the peculiar way that her neighbor would some times hang her laundry on the clothesline. In the month before

Cose Examples

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admission, the son reported that his mother's delusions had become more bizarre. She claimed that the dope pushers were shining laser beams into her windows at night, causing the curlers in her hair to heat up. The son finally convinced his mother to see her internist several weeks before her admission. The internist had evaluated MP briefly and prescribed a combination of chlordiazepoxide and amitriptyline for her in an unknown dosage. The son reported that his mother had worsened on this medication. She became very confused and wandered aimlessly around the house. She claimed to see parts of bodies lying on the furniture. The son had decided that MP had to see a psychiatrist, and she offered little resistance in her very confused state. Despite her protests, she had even agreed to sign for a voluntary admission. The patient's son was 27 years old; he had continued to live at home because of uncertainty about "what I wanted to do with my life." His mother has supported him financially and did not mind his sharing their ratJ1er large house. He believed that his mother had been excessively demanding of him over the prior year, however, and felt that she had been "holding him back" from going out on his own. He seemed irritated when discussing this situation. MP's son reported that his mother had always been in good health except for her cataracts. She was taking no medications except for the psychotropic. He noted that she had been sleeping much less in the few weeks before admission, but attributed this to her being "worked up over those crazy ideas." He was unaware of any change in her weight or appetite. At that point the nurse reported that the patient had calmed down enough to be interviewed. Examination revealed MP to be disoriented to place and time. She was poorly attentive and uncooperative with fonnal mental status testing. She had marked loosening of her associations,jumping from topic to topic unrelated to questioning. She per-severated on the theme of the drug dealers, whom she believed even then were trying to kill her.

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112

The Psychiotric Treatment of Alzheimer's Disease

insidious, and BB refused to acknowledge that any of her family's concerns were justified. Her son-in-law was a physician who insisted that the symptoms must be manifestations of depression since BB had a 30-year history of recurrent depressions. However, the pre cipitants and characteristics of prior depressive episodes were always more clear-cut, and responses to pharmacologic interven tions for depression were always dramatic. The patient had not responded to antidepressant medication during this episode, sug gesting a diagnosis other than depression. For 2 years, BB was reportedly belligerent when it. was pointed out that she had not completed a task or was kept from wandering. She was still able to pcrfonn most routine household tasks such as cleaning and shopping and cooking, but was having increasing difficulties with judgment. Despite her daughter's reports of BB's long-standing marital difficulties, which seemed to be worsening as the couple aged, both BB and her husband refused to acknowl edge them. There was also a history of alcohol misuse by the patient, which had reportedly stopped 5 years earlier. BB showed no neurological abnormalities or major general medical diagnoses during a complete medical evaluation. A CT Scan of the brain showed mild cortical atrophy, and EEG showed diffuse slowing which was consistent with a degenerative dementia. BB was referred to psychiatry services for consultation and psy chological testing. WAIS-R, Wechsler Memory Scale, Aphasia Screen ing Test, ThT, and Rorschach were administered over three test sessions. The patient was able to travel independently to and from the hospital for testing, hut seemed very disorg:mized in test situa tions. She was cooperative with cognitive tests, but was very guarded on personality tests. She scored in the low-averdge range on WAIS scores without significant subtest variability. Her aphasia screening was within nonnal limits, as were writing and copying geometric designs. Projective tests showed nonresponses such as "I don't know" or "I can't think of it." Affect was absent from her responses, and stories had a vague and repetitive quality. She was not readily engaged in the initial interviews, and responded only to direct questions, offering no spontaneous verbalizations.

Cose Examples

113

BB had worked briefly before her marriage as a typist, but stopped after marrying to raise her two children. She had few hobbies or interests and relied heavily on her husband for decisions. BR's family labeled her a dependent personality. BB was one of 14 children, abandoned by her father before the age of ten. Her marriage of over 50 years had always been strained because of her husband's lack of acceptance of her dependent needs. There were frequent discussions of divorce or separation throughout the marriage, and her husband had known extramarital affairs. This seeming recapitulation of her childhood family situa tion had not been adequately worked through in her past psychiat ric treatments. Additional family tension was present with BB's children, who felt that their parents had been unable to provide adequate emotional support, and felt bitter and angry with them. When first seen in the psychiatric hospital, BB was diagnosed as having primary degenerative dementia of the Alzheimer's type with depressive features. BB's family showed marked denial. For BR's children, this denial seemed to be related to a growing realiza tion that their childhood wishes could never be realized. For BB's husband, he seemed to be overwhelmed by the caregiving demands and lacked knowledge about the disease. The treatment plan consisted of three m�jor elements: 1) Enroll BB in a structured daycare center progrnm and provide supportive weekly psychotherapy. 2) Help BB's daughter deal with her depres sion and guilt regarding her sense of helplessness and her need to mourn unfulfilled wishes about how she ·wished her relation to her mother could be. Help BB's husband confront his denial and obtain a better understanding of his wife's cognitive deficits and needs. 3) Avoid antidepressant� due to the labile nature of BB's moods and to the past failure of such medications. Prescribe haloperidol as needed at times of extreme belligerence. Course

After 18 months of relative adjustment, there was an acute change in BB's behavior. She refused to go to daycare, became quite

ll4

The Psychiatric Treatment of Alxheimer's Disease

paranoid, rigid, and argumentative, and insisted on wearing her best clothes and mink coat eveywhere. Her husband instructed her not to wear her coat, and the patient complied by throwing her coat away. She avoided her husband's criticisms by locking herself in the elevator. This prompted a brief hospitalization. With the abrupt change in the patient's behavior, it was necessary to reassess the possibility of an acute medical problem or an acute org-anic brain syndrome, reevaluate her medication regimen and begin intensive work with the family. General medical �auses'were ruled out. The history, which was obtained from several sources, suggested that BB had experienced an assault to her self-esteem at the daycare center, and was responding defensively against this. At the time of rehospitalization, her son-in-law again insisted that a pseudodernentia was being overlooked. BB's husband became disengaged again, and her daughter became increasingly uncer tain and depressed. Addressing these issues was a primary goal of hospital treatment. BB's functional capacities were retested, diagnostic tests were repeated, and her medications adjusted. Despite confirmation of a deterioration in global functioning withouta major depression, the family remained unconvinced. When BB refused to return to the daycare center, home assistance was provided. Three months after discharge, RB's son-in-law arranged for an out-of-state assessment by other "experts.tt v\lhen the original diagnosis was confirmed, the family felt further psychiatric care was not needed, and the patient was lost to follow-up.

Discussion lreatment plans for Alzheimer's disease patients may need to be shelved temporarily when external stressors precipitate crises. The patient may then need short-tenn hospitalization for relief. Unless the family can work through their reactions to the patient's illness, their reaction patterns may recur. In BB's case, the family, especially her physician son-in-law, resisted and criticized each diagnosis and treatment. When there was no improvement in BB's

Cose Examples

ll5

condition, he continued to blame the psychiatrist for a misdiagnosis. Such reactions are common and should themselves be issues to be resolved in counseling. Even the diagnosis of organic brain syndrome need not engen der hopelessness and assumptions that treatment can accomplish nothing. Premature withdrawal from treatment, as was apparently true for BB, may rob the patient of an opportunity to ameliorate some of the symptoms.

CASE EXAMPLE 6 Key Clinical Issues Deceptive (atypical) early manifestations of Alzheimer's disease The natural history of the disorder and changing treatment needs that accompany it Family system dynamics

The Case BC was a 67-year-old married woman. After an initial diagnosis of Alzheimer's dementia when she was 64, her husband sought a second opinion. A more comprehensive evaluation was then car ried out by a second primary care physician, who sought neurolog ical consultation. No focal neurological features were noted, and the patient's physical examination, EKG, and blood and urine chemistries were all within normal limits. A CT Scan showed no atrophy or evidence of other brain disease, and an EEG was read as normal. A RISA Scan, LP, ANA, and a Dexamethasone Suppres sion Test were performed, and also determined to be normal. This second workup revealed no other brain disorder or general medi cal condition, the main findings being from the patient's history, which revealed a past episode of depression and a question of paranoia. Given the possibility of a pseudodementia, pharmacologic intervention was initiated with psychotropic medication. Respec tive 2-month trials on maprotiline, thiothixene, chlorazepate,

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Bibliography

BIBLIOGRAPHY

135

Brood Overview (Epidemiology, Research, Services, Financing, Policy) US Congress, Office of Technology Assessment (1987). Losin a million minds. g Confronting lite tragedy ofAlz.lwimer's distase and other Mmentiai. Washington, DC: US Government Printing Office (OTA-BA-323).

BRIEF OVERVIEWS

Family References

Cohen, G.D. (1987). Alzheimer's disease. In C. I.. Maddox (Ed.), EnCjv:loprdia of Aging (pp. 27-30). New fork: Spring..r. Katzman, R. ( 198fi). Alzheimer's disease. NP!.u Eng/andjournal of Medicine, 31(13), !J&l-973. W11r1rnan. RJ (1985). AlLhcimer's disea.se. S<i<'ltlijic Amn-icau, 252(1), 62-74.

Cohen, 0., & Eisdorter, C. (1986). The loss of self. New York: Nonon. Mace, N.L., & Rabi11S, PV. (1981). The 36-haur day. Baltimore: Johns Hopkins University Press.

JOURNAL IN-DEPTH REVIEWS Strong on Both Basic Science and Clinical Issues Rcisberg, B. (Ed.). (l!JR'.,). A/zlu,imer'., disease. New York.: Free Press.

Strong on Clinical and Policy Issues (;ilhooly, L.M., Zarit, S.H., & Birren, .J.F,. (Eds.). ( 1 \)86). The dnnenli11s: Policy and management. Englewood Cliffs. NJ: Prcnticc-l lall. lvliller, N.£., & Cohen, CJ>. (Eds.). ( I !l8 I). Clinical nsf1rct1 nf AlzJ1Pimer'.1 disease and s1.'fl.ile demenlia. New York.: Raven Press.

Strong on Basic Science Kav.man, I{., Terry, RO., & Bick. K.I.. (Eds.). (l!l78). Alzheimer's disea,e: senile demmtia and ,-;!lated <lisr,rder.,. ;-.;cw York: l{aven Press. Kallman. I{. (Eel.). ( 198:1). Biologicalaspecl1 ofAl::Jwimff'.1dimue. Cold Spring Harbor Laboratory, NY: R�nbury Reports.

134

.4lzheimer's LJiseav. mul Associated DisQT'ders, S.S. Maisuyama & L.E Jarvik (Eds.). l."lwrence, KS: Western Geriatric Research Institute. The Journal contains regular articles plus abstracts of articles on Alzheimer's dfscase from other journals and books.

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The Psychiatric Treatment of Alzheimer's Disease

140

BLESSED DEMENTIA SCALE

Changes in Personality, Interests, Drive

Changes in Performance of Everyday Activities l. Inability to perform household tasks 2. Inability to cope with small sums of money 3. Inability to remember shorl list of items, e.g., in shopping 4. Inability to find way about indoors 5. Inability to find way about familiar street� 6. Inabi litv, to interpret. surroundings ' (e.g. ' to recognize ·,_ whether in hospital, or at home, to discriminate between patients, doctors and nurses, relatives and hosptial staff, etc.) 7. Inability to recall recent events (e.g., recent outings, visits of relatives or friends to hospital, etc.) 8. ·tendency to dwell in the past

1 lfi 0 I ½ () 1

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½ 0 1 ½ 0 1 lf.! 0

Changes in Habits 9. Eating: Cleanly with proper utensils Messily with spoon only Simple solids, e.g., biscuits Has to be fed 10. Dressing: Unaided Occasionally misplaced buttons, etc. Wrong sequence, commonly forgetting items L"nable to dress 11. Complete sphincter cont.rol Occasional wet beds Frequent wet beds Double incontinent

141

Appendix: Rating Scales

12. 13. 14. 15. Hi 17. 18. 19. 20. 21. 22.

No change Increased rigidity Increased egocentricity Impairment of regard for feelings of others Coarsening of affect Impairment of emotional control, e.g., increased petulance and irritability Hilarity in inappropriate situations Diminished emotional responsiveness Sexual misdemeanor (appearing de novo in old age) Interest� retained Hobbies relinquished Diminished initiative or growing apathy Purposeless hyperactivity

O 1 I l I l l I 1 0 1 l l

Total Scoring

0 2

3 0 1

3 0 l 2 3

Score of 4 or less-little or no deterioration of cognitive function Score of 5 or greater-consistent with definite and marked cognitive deficts See Blessed, Tclmlinson & Roth, 1968

142

The Psychiatric Treatment of Alzheimer's Disease

Appendix: Roting Scoles

GERIATRIC DEPRESSION SCALE

HACHINSKI ISCHEMIC SCALE (2

1. Onset of symptoms was abrupt 2. Stepwise deterioration

3. Fluctuating course (returns to near normal function for a day or more at a time 4. Nocturnal confusion (score only if symptoms are essentially confined to the night hours) 5. Relative preservation of personality 6. Depression 7. Somatic complaints 8. Emotional incontinence 9. History of hypertension 10. History of strokes (family was told by a physician that the patient had had a stroke) 11. Evidence of associated atherosclerosis (EKG, chest x-ray, pulse deficits, etc.) 12. Focal neurological symptoms 13. Focal neurological signs Total:

(2 (1 (1 (1 (1 (1 ( 1)

(2) ( 1)

(2 )

(0-18)

Scoring Total score of 7 and above-consistent with a diagnosis of multi infarct dementia Score of 4 or less-suggestive of primary degenerative dementia See Hachinski, Lassen & Marshall, 1974

143

Choose the best answer for how you felt over the post week 1. 2. 3. 4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

20.

21. 22. 23. 24. 25. 26. 27. 28.

29. 30.

Are you basically satisfied with your life? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you often get bored? Are you hopeful about the future? Are you bothered by thoughts you can't get out of your head? Are you in good spitits most of the time? Are you afraid that something is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you often get restless and fidgety? Do you prefer to stay home, rather than going out and doing new things? Do you frequently worry about the future? Do you feel you have more problems with memory than most? Do you think it is wonderful to be alive now? Do you often feel downhearted and blue? Do you feel pretty worthless the way you are now? Do you worry a lot about the past? Do you find life very exciting? Is it hard for you to get started on new projects? Do you feel full of energy? Do you feel that your situation is hopeless? Do you think that most people are better off than you are? Do you frequently get upset over little things? Do you frequently feel like cry·ing? Do you have trouble concentrating? Do you enjoy getting up in the mornings? Do you prefer to avoid social gatherings? Is it easy for you to make decisions? Is your mind as clear as it used to be?

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The Psychiatric lieotment of Alzheimer's Disease

Carcinomas, 46 Caregivers children a.<, 61 denial by, 62

rc:lctions to Alzhcimer':s disease by, 26

Catastrophic reactions, 57 Catatonic schizophrenia, 43 Causes of /\11.heimer's disease autoimmune theory of, 10 chemical theories of, 10-11 genetic theory of, 11 no1mal aging and, 12 slow virus as, I 0 vascular theory of, 9-10 Central nervous S)'l'tem stimulants, 80 Chemical theories, 10-1 I Children of Alzheimer's patients, 54, 60, 61 in case histories, 106-7, 113, 114 Chlmpromazine. 74 Choline,81 Choline acetyl tranferase (CAT), 80 Chronic institutional settings, 84-85 Clinicoµalhologic correlations of Alzheimer's diSt!a,e, 17-20 behavioral and affective changes, 20-24 family and .:aregiver reactions to, 24-26 Cognition dysfunctions of, 4 in carlv states of Alzheimer's disease, 18-19 medications for improvement of, 78-82 normal change� in, with aging, 7 -9 Parkinson's disease and, :'>0-:, I pseudodementia and, 42 remotiva6on tht>rApy for: 65 training in, 66

Cohen, 0., 21 Cole,J.O., 75-76 Communicaciou:s, in late-<lementia phase. 22

Community i.ervict:s for Alzheimer's

dis<"a.se, 83 Computer-assisted tomob'll.tphy (CT &ans), 6 Conditioning techniques, 6-1 CorticaJ dementia, 17-18 Costs of Al1.heirncr's disease, 6, 13-14, 123 Countertrdosference, 55 Creutzfold:fakob disease, 51 Cushing's syndrome, 47-48 Day care programs, 83-84 Defense mt,chanisms, 22, ;i5-58 negenemrive diseases, ,19-51

Delirium in case histories, 104 induced by medications, 32 medications inducing, 68 Ddusional ideation, 22 Delusions, 4 in case histories, l00-106 Dementia alcoholism and, 49 Blessed Dementia Scale fo r, 140-41 from hr,1in tumors, 45 carcinoma..� and, 46

Dementia Behavior Scale for, 145-47 depression symptoms and, 75 dialysis and, 49 ego dysfunction in, 56 mectications for, 67-82 " metabolic disorders and. 47 multi-infarct, 44 Parkimon's disea!le and, 50 pituitary diseases and, 47-48 pseudodementia and, 41-43 psychotherapy for patients with, 58-60 syphilis and, 46, 47 thyroid disease and, 47 vitamin deficiencies and, 48 Dementia Behavior Scale, 145-47 lknial, 22, 25 hy caregivers, 62 as defense mechanism, 57 Dependency-induc ing mcdi(atiuns, 68-69 Depression, 4, 21, 22 auxiety ancl sleep disturbance linked to, 70 in case histories, 98-!)9, 112, 128, 130 defense mechanism, against, 57 electroconvulsi,-e therapy for, 77-78 among family members. 54-55 Gerialric Depression Scale fot; 143-44 medica1ions in crcatment of, 75-77 Parkjnson's disease and, 50

pseudcKkmentia and, 12 suicidal, 85 IJiagnoses of Alzheimer's disease, 5

age-assodat.ed n1cmory impainnent

and, 41 alcoholism and clerncntia in, 49 brain tumors ancl, 45 carcinoma and dementia in, 46

criteria and rests for, 35-40

defenses against, 22 degenerative dis<"ases and, 49-51

Index

denial of, 25 dial)'sis dementia and, 49 dillerential, 41 drug-induced encephalopathy and, 43-44 infections and inflammatory diseases and,46-47 markers for, 6 medical a,;sessments f01; 32-33 medical and psychiatric histories for. 31-32 metabolic disorders and, 47 multi-infarct dementia and, 44 neuropsychological tt::sting for, 33-34 nonnal pressure hydrocephalus and, 45 parath�Toid disease and, 48 pituitary disease and, 47-48 pseudodcmentia and, 41-43 psychiatric assessments for, 33 in psychiatric hospitals, 85 sulxlurnl hematornas and, 46 thyroid disease and, 47 vitamin deficiencies and, 48 Diag,zostic and Stntistical Manual ofMmtal Disarderl, Third Edition, Revised (DSM-III-R), 4, 5, 97 Dial)'l'iS dementia, 49 Diazepam, 121 Differential diagnoses of Alzheimer's disease, 41. See also Diagnoses of Al:iheimer's disease

tesls for, 3�0 Dihydroergotamine, 79, 80, 82 Dosage of medications of antidepressants, 76-77 of neumlcptics, 73-74 Oown's Syndrome, 11 Oreams, 57 "Drug holidays," 75 Drugs, See alw Medications encephalopathy induced by, 43-44 neurotransmitters, 10 Ego functions, 55-58 Electroconvulsive therapy (ECT), 77-78 Emotions liabilty of, 67 mood disorders, treatment of, 75-77 Encephalopathy, drug-induced, 43-44 Excess disability states, 12 Families, 60-62. See also Children of Alzheimer's patients; Spouses

151

in behavioral intenentions, 63 in case histories, I 13-15 Down's Syndrome in, 11 heredity within, 7 patients' reflecting hopelessness in, 20 in psychotherapeutic approach, 54-55 reactions lo Alzheimer's disease bv, 24-26 remotivarion therapy by, 65 Family therapy, 24, 25, 54, 60-62 Ferencz,, S., 59 Forgetfulness, 18 General hospitals, 88-90 Genetic markers, 6, 7 Gene1ic theory, I 1 Geriatric Depression Scale, 143-44 Geriatric psychiatry units,86 Cerovital, 80 Goldfarb, A.I., 59 Gro\jahn,J.M., 58-59 Group therapy, remotivation therapy in, 65 Hachinski lschemic Scale, 142 Hakim, S., 45 Hallucinations, in case histories, I JO Haloperidol, 69, 73 Hauser, S., 56 Head injurie:s, 7 Hematomas, subdural, 46

Hcreditv, 7. 11 fears �f in heriting Alzheimer's disease, 25 History of Alzheimer's disease, 3-5 Hollos,S., 59 Hopelessness, 20 Hospitali1.a1ion in case histories, 125, 131-32 in chronic institutional settings, 84-85 family therapy and, 62 in general hospitals, 88-90 "partial," 84 in psychiatric hospitals, 85-88 Huntington's chorea, 50 Hurst, L., 74 Hydergine, 79 Hydrocephalus, nonnal pressure (NPH), 45 Hyperactivity, 57 Hyperparathyroidism, 48 Hyperthyroidism, 47 Hyµomania, 77 Hypoparathyruidism, 48

154

The Psychiatrir Treatment of Al:rheimer's Disease

Tests Blessed Dementia Scale,140-41 in case histories, 112, 115, 119 Dementia Behavior Scale, 14.',...47 diagnostic,35-37 for differential diagnoses of Alzheimer's disease, 38-40 of ego functions, 56-57 Geriatric Depression Scale, 143-44 Hachinski lschemic Scale, 142 Mini Mental Stare Exam, 138-39 neump.sychological, 33-34 rating scales,137 Tetrahydroaminoacridine (THA), 81 Thioridazine, 69, 73 Thyroid disease, 47 Toxicity theory, 11 lranq uiliiers, 71 'fransferencc,58, 59 countenransference and, 55 lransmissible agent theory, I 0 liazodone, 76 lreatment, 1-2, 12-14, 53 behavioral interventions, 62-67 medication in, 67-82 for pseudodementia, 42

psychotherapeutic and psychosocial, 53-62 settings for and psychiatrist's role in, 82-90 Treatment settings, 82-83 general hospitals, 88-90 institutional, chronic,84-85 outpatient, 83-84 psychiatric hospitals, 85-88 Tocyclic antidepressants, 76 lhmors in brain, 45 Vascular theory, 9 Vasodilators, 78-80 Vasopressin, 82 Verwoerdt, A., 57, 59-60 Virus theory, IO Visiting Nurses Association (VNA), 83 Vitamin deficiencies, 48 Weight loss, in case histories, 105 Wernicke-Korsakoff syndrome,17, 49 Withdrawal symptoms, from medications, 68-69 Women, 7 Workgroup on Diagnosing Alzheimer's Diseas", 35

GAP COMMITTEES AND MEMBERSHIP

COMMITTEE ON AooLESCENCE Clarice J. Kestenbaum, New York, NY, Chairperson Hector R. Bird, New York, NY Ian A. Canino, New York, NY Warren. J. Gadpaille, Denver, CO Michael G. Kalogerakis, New York, NY Silvio J. Onesti,Jr., Belmont, MA CO�fMITIEE ON ALCOHOi.iSM AND THE ADDICTIONS Edward]. Khantzian, Haverhill, MA, Chairperson Margaret H. Bean-Bayog, Lexington, MA Richard J. Frances, Newark, NJ Sheldon I. Miller, Newark, NJ Robert B. Millman, New York, NY Steven M. Mirin, Westwood, MA Edgar P. Nace, Dallas, TX Nonnan L Paul,Lexington, MA Peter Steinglass, Washington, DC John S. Tamerin, Greenwich, CT

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COMMITIEEOK CHIU) PSYCHLATR\:' Theodore Shapiro, New York, NY, Chairperson James M. Bell, Canaan, NY Harlow Donald Dunton, New York, NY Joseph Fischhoff, Derroit, Ml Joseph M. Green, Madison, ½1 John E McDennott,.Jr., Honolulu, HI John Schowalter, New Haven, CT Peter E. Tunguay, Los Ange !es, CA Lenore Terr, San Francisco, CA

Cmn,ITITEE ON COLLEGE STUDEN1S Myron B. Liptzin, Chapel Hill, NC, Chairperson Robert L. Arnstein, Hamden, CT Varda Backus, La Jolla, CA Harrison P. Eddy, New York, NY Mall<ah Tolpin Noonan, BrookJine,

Gloria C. Onque, Pittsburgh, PA Elizabeth Aub Reid, Cambridge,MA Earle Silber; Chevy Chase, MD Tom G. Stauffer; White Plains, NY COMMITTEE ON CULTURAL PSYCHIATRV Ezra E.H. Griffith, New Haven, CT, Chairperson Edward F. Foulks, New Orleans, LA Pedro Ruiz, Houston, TX John P. Spiegel, Waltham, MA Ronald M. Wintrob, Providence, RI Joe Yamamoto, Los Angeles, CA COMMITf££0NTHEFAMIIY Herta A. Guttman, Montreal, Quebec, Chairperson W. Robert Beavers, Dallas, TX Ellen M. Berman, Merrion, PA Lee Combrinck-Graham, Evanston, IL Ira D. Glick, New York, NY Frederick Gottlieb, Los Angeles, CA Henry U. Grunebaum, Cambridge, MA Judith Landau-Stanton, Rochester, NY Ann L. Price, Hartford, CT Lyman C. Wynne, Rochester, NY 155

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