Beyond Cognition: Managing Alzheimer’s as an Integrated Neurodegenerative–Neuropsychiatric Syndrome

Dr. Cabral:
This is CE on ReachMD. I'm Dr. Dani Cabral. With me today is Dr. Marwan Sabbagh.

Marwan, what are the neuropsychiatric symptoms of Alzheimer's disease? And what impact do these have on patients and care partners?

Dr. Sabbagh:
Yeah, Dani, this is a big deal. This, of course, is a challenge both to neurologists and psychiatrists, because the reality is that almost 7 million people have Alzheimer's dementia, and yet morbidity and mortality, a lot of it is driven by the fact that there is a lot of neuropsychiatric symptoms.

Both agitation and psychosis are highly prevalent. When you actually look in a patient care setting, 53% of patients in institutionalized care actually have neuropsychiatric symptoms, such as psychosis and agitation, and that's 45% in the community. And it is dependent on the severity of their dementia. By the time they're in the moderate to severe stage, we're talking about 3/4 of patients having neuropsychiatric symptoms. And so we know this is a huge complication.

The rule of thumb is the happy demented stay home, and the agitated demented don't stay home. It's kind of the rule of thumb. And you know, and I know this because in our practices, we're getting calls not for the happy demented, we're getting calls for the agitated, the wandering, the screaming, the paranoia, et cetera.

And so we can actually look at the IPA definition of agitation in patients with cognitive disorders. They can have excessive motor behaviors, pacing, rocking, gesturing, pointing fingers, restlessness, performing repetitious maneuvers, such as what we would call aberrant motor behavior. They can have verbal aggressive behaviors: yelling, speaking loudly, using profanity, screaming, shouting. They can have physical things: grabbing, shoving, pushing, resisting, hitting others, kicking, scratching, biting, and throwing objects, hitting self, slamming doors, tearing things, and destroying property.

I have to tell you, I've seen all of these in my patients over the years, and it's very distressing both to the facilities, to the patients. It's very upsetting to family members when they see this happening, and especially if they can't do anything about it.

When we actually look at it, there's been lots of different scales you can use to measure it, but some of the studies have used the instrument called the CMAI, the Cohen-Mansfield Agitation Index, which also has 29 domains and 29 behaviors. But there are other instruments, such as the Neuropsychiatric Inventory as well.

So we have ways to measure it objectively, but we also know that the reason you want to address it very specifically is because we know it's associated with an accelerated disease, functional decline, quality of life, urge to use medicines that may or may not be on label, may or may not be in the benefit of the patient, may accelerate things, more risk of falls, potentially risk of death.

When you actually look at the data, neuropsychiatric symptoms are associated with overall increased morbidity and mortality, more infections, 18% more, more fractures, 29%, 58% more falls, and other neuropsychiatric symptoms as well, more than double. We know that they tend to be hospitalized twice as more and stay longer, almost 4 times longer in institutional-based care, and they are a huge driver of total cost, doubling the total cost of care.

So we do know that we need to be able to address the neuropsychiatric symptoms, and in so doing it, we need to be able to reduce them, and we'll spend some time in other episodes talking about the mechanisms and the treatment targets.

Dr. Cabral:
Marwan, I think coming up with this International Psychogeriatric Association definition for agitation is huge, because it's more objective. At least clinicians can say, is it verbal aggression, motor aggression, and the other area. And so at least we can start to better diagnose specifically, and then this can help us come up with better treatments for many reasons, symptomatically and also addressing the biology of the disease.

So thank you so much for that. I think that was a great overview, and our time is up. So thanks for listening.