Psychiatric Aspects of Dementia

Abstract

Purpose of review: The psychiatric aspects of dementia are increasingly recognized as significant contributors to distress, disability, and care burden, and, thus, are of increasing interest to practicing neurologists. This article examines how psychiatric disorders are entwined with dementia and describes the predictive, diagnostic, and therapeutic implications of the psychiatric symptoms of dementia.

Recent findings: Psychiatric disorders, particularly depression and schizophrenia, are associated with higher risk for late-life dementia. Psychiatric phenomena also define phenotypes such as frontotemporal dementia and dementia with Lewy bodies, cause distress, and amplify dementia-related disabilities. Management requires a multidisciplinary team, a problem-solving stance, programs of care, and pharmacologic management. Recent innovations include model programs that provide structured problem-solving interventions and tailored in-home care.

Summary: There is new appreciation of the complexity of the relationship between psychiatric disorders and dementia as well as the significance of this relationship for treatment, community services, and research.

Figure 11-1

Algorithm for identifying the neurodegenerative types of dementia. The diagram shows how symptom clusters and the syndromes they signify drive the differential diagnosis of dementia. Cognitive and motor syndromes define pathways and, when complemented by psychiatric states (red text), may define specific dementia diagnoses (such as the behavioral variant of frontotemporal dementia [bvFTD], frontotemporal dementia with amyotrophic lateral sclerosis [FTD-ALS], and dementia with Lewy bodies [DLB]). AD = Alzheimer disease; CJD = Creutzfeldt-Jakob disease; HD = Huntington disease; PCA = posterior cortical atrophy; PDD = Parkinson disease dementia; PIA = progressive ideomotor apraxia; PLA = progressive logopenic aphasia; PNFA = progressive nonfluent aphasia; PSP = progressive supranuclear palsy; SCA = spinocerebellar ataxia; SD = semantic dementia. Reprinted with permission from Devineni B, Onyike CU, Psychiatr Clin North Am. www.sciencedirect.com/science/article/pii/S0193953X15000271. © 2015 Elsevier Inc.

Figure 11-2

DICE (describe, investigate, create, and evaluate) approach to the examination, formulation, and management of dementia-related behavioral problems. A two-part flow diagram is shown, illustrating the socially dynamic context of the DICE approach (ie, the triad of patient, caregiver, and environment), the progression in its implementation, and the recursive routines for managing high-acuity states. The bidirectional arrows in the triad emphasize the reciprocity of the dynamics that shape many behavioral problems encountered in dementia care.Modified with permission from Kales HC, et al, BMJ. www.bmj.com/content/350/bmj.h369. © 2015 British Medical Journal Publishing Group.