Treating Dementia: Progress and Promise

Dementia is defined as an acquired disorder of multiple cognitive impairments occurring in clear consciousness. This definition dates back 200 years to Esquirol and appropriately does not include symptoms that are referred to as neuropsychiatric, noncognitive, psychiatric, or behavioral and psychological symptoms of dementia. Nonetheless, such symptoms have long been recognized as common in the dementias. When Arnold Pick defined the lobar dementia that bears his name more than 100 years ago, he associated behavioral abnormalities with frontal lobe involvement, and the first case described by Alois Alzheimer presented with the delusion that her husband was having an affair (“delusional jealousy”) and had a 5-year hospitalization characterized by agitation, persecutory delusions, and sleep disorder. Furthermore, clinically relevant depressive symptoms occur in a high percentage of cases of Alzheimer disease (AD). The pioneering work by Blessed et al. in the 1960s demonstrated that senile dementia was most commonly characterized by the plaques and tangles first described by Alzheimer. This led to a research, public education, and clinical focus that changed the perception of AD from being an obscure, rare disease to its current status as a recognized major public health problem. Beginning in the 1970s, studies identified the high prevalence of the neuropsychiatric symptoms and linked them to adverse outcomes in both the person with the illness and the care provider. By the late 1980s, case-register-based studies and review articles highlighted the association between these symptoms and adverse outcomes such as nursing home placement, patient mortality, and carer well-being. The genesis of neuropsychiatric symptoms is complex and likely includes both environmental stimuli and disruption of normal brain function by disease. Treatment with either nonpharmacologic therapies or cholinesterase inhibitors improves neuropsychiatric symptoms, but the improvement is modest at best. Neuropleptic, antipsychotic drugs have been consistently shown to have modest benefit in treating psychotic symptoms (hallucinations and delusions) and agitation, averaging 19% over placebo, but side effects are significant and serious, and the benefit/risk ratio is far from desirable. Interventions targeting the carers of persons with dementia have also been effective, and these benefit both the caregiver and the person with the disease and may delay long-term care placement. Thus, research has shown that interventions targeting both the neuropsychiatric symptoms and the caregiver distress can be effective despite this complex causal web and a limited understand of the neurobiology of the dementias in general. This edition of the journal contains four articles that address these difficult issues and demonstrate that progress in addressing them continues to be made. Current practice guidelines recommend the use of nonpharmacologic treatment for the neuropsychiatric symptoms of dementia before pharmacotherapy is initiated because of the toxicity of the drugs and their limited efficacy. However, empirical support for this recommendation is limited. Ballard et al. report on an open trial of brief psychosocial therapy (BPST) at a variety of centers in Great Britain. This treatment model uses a manualized approach to providing music, removal of environmental triggers, or social interaction. The inclusion criteria for the trial included the presence of agitation and a score on the