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Dementia: Managing Neuropsychiatric Symptoms

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Although cognitive disturbances such as memory and language impairment are the most recognized symptoms of dementia, the neuropsychiatric symptoms of dementia (NPSD) are often more concerning and can cause considerable disability and caregiver distress. The total annual cost of treatment for a patient with Alzheimer's disease (AD) who is living at home is estimated at $14,500. The direct management of behavioral and psychological symptoms accounts for 30% of this total. The last drug approval by the FDA for treatment of AD occurred approximately 15 years ago. Currently, no drug is FDA approved to treat NPSD, and no drugs for this indication are on the horizon. One second generation antipsychotic, risperidone, is approved in the United Kingdom and Australia for treating aggressive/assaultive behavior due to AD that poses harm to caregivers or the patient.

Nondrug approaches to managing NPSD, while recommended, are of questionable clinical value in reducing agitation or aggression in nursing home and assisted living facility residents with dementia. A variety of drugs are prescribed (off label) every day for behavioral symptoms related to dementia, despite the lack of FDA-approval. Many distinct types of drugs have been routinely used and/or studied to treat NPSD, including acetylcholinesterase inhibitors, antiepileptics, benzodiazepines, antipsychotics, antidepressants, and most recently, a combination of dextromethorphan and quinidine. None have emerged as clearly effective, resulting in many instances where a combination of medications is prescribed.

This issue will review medications commonly prescribed for the management of dementia-associated neuropsychiatric symptoms, and discuss the pros andcons of selected agents. It is intended to serve as a guide to the safe, appropriate use of medications to manage troublesome behaviors related to AD, vascular dementia, dementia of the Lewy body type, and frontotemporal lobe dementia – the most prevalent types of dementia in the US and Europe.


Publication Date: 08/20/2016
Expiration Date: 08/20/2019
CE Credit: 1.5 (0.15 CEU)
Type of Activity: Knowledge-based

This program was developed by The Rx Consultant and published by Continuing Education Network, Inc. The Rx Consultant accepts no advertising or financial support from the pharmaceutical industry and is funded solely by the purchase of programs. The Rx Consultant is dedicated to providing unbiased, balanced information to health care practitioners.

Programs developed by The Rx Consultant are written by health care providers with expertise in the topic area, peer-reviewed, extensively edited, and fact-checked. This development process was created to insure that every program presents information that is current, accurate, relevant to "real world" health care providers, and written in an easy reading, "plain English" style.


Ron Finley is a volunteer faculty member at the UCSF Memory and Aging Center and a Health Sciences Clinical Professor, UCSF School of Pharmacy.

Expert Editorial Advisor: Kirby Lee PharmD, MA, MAS is Associate Professor of Clinical Pharmacy, UCSF School of Pharmacy. His practice focuses on medication management in older adults with cognitive impairment, memory and behavioral changes. Timothy Cutler is Professor of Clinical Pharmacy, UCSF School of Pharmacy. He is currently the Divine Family Endowed Chair in Clinical Pharmacy and the Director of the UC Davis Sacramento Experiential Program.

Disclosure Statement

Mr. Finley, Dr. Stock, and Dr. Farnen report no financial relationship with the manufacturer(s) or provider(s) of any commercial product(s) or service(s) that appear in this issue.

Target Audience

This accredited program is targeted to pharmacists .

Goals & Objectives

At the conclusion of this program, participants will be able to:

    1. Describe the neuropsychiatric symptoms of dementia and the factors that may lead to problem behaviors. Discuss how the type of dementia may lead to certain behavioral symptoms and impact treatment choice.
    2. Review the non-drug and drug therapy considerations for common behavioral and psychiatric symptoms of dementia. Describe the role of the combination pill containing dextromethorphan and quinidine.
    3. Discuss the efficacy, side effects, and dosing for the most frequently used antipsychotics and antipressants for NPSD. List drug classes that have not been proven effective and/or have more risk than benefit for the management of NPSD.

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The Rx Consultant is a publication of Continuing Education Network, Inc.

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Continuing Education Network, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education as a provider of continuing pharmacy education.

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Continuing Education Network is approved by the California Board of Registered Nursing, Provider Number CEP 13118. Programs approved by CA BRN are accepted by most State Boards of Nursing.

ACPE Universal Activity Number: 0428-0000-16-007-H01-P

Exam & Credit Statement Procedures

Upon successful completion of this program and the post test (70%), 1.5 hours of continuing education credit will be awarded. To receive credit and your exam score, please complete the exam questions and program evaluation.

Editorial and Review Board

Chief Editor and CE Administrator

Terry M. Baker, PharmD

Managing Editor

Tracy Farnen, PharmD

Associate Editors

James Chan, PharmD, PhD
Pharmacy Quality and Outcomes Coordinator
Kaiser Permanente
Oakland, CA

Associate Clinical Professor
School of Pharmacy
University of California San Francisco
San Francisco, CA

Richard Ron Finley, B.S. Pharm.,R.Ph.
Clinical Pharmacist (volunteer faculty)
University of California, San Francisco (UCSF) Memory and Aging Center
Lecturer (Emeritus) UCSF, Department of Clinical Pharmacy
Health Sciences Clinical Professor, UCSF School of Pharmacy
San Francisco, CA

Consultant Pharmacist
Ray Dolby Brain Health Center, Sutter Health/CPMC
San Francisco, CA

Consult Pharmacist Aging and Adult Health Services
San Francisco Health Department
San Francisco, CA

Julio R. Lopez, PharmD, FCSHP
Chief of Pharmacy Service
VA Northern California Health Care System

Adjunct Clinical Professor
College of Pharmacy
Touro University
Vallejo, CA

Assistant Clinical Professor
School of Pharmacy
University of California, San Francisco
San Francisco, CA Adjunct Professor
Thomas J. Long School of Pharmacy
University of the Pacific
Stockton, CA

Visiting Associate Professor and Lecturer
Nursing School
Samuel Merritt University
Oakland, CA

Pamela Mausner, MD

Helen Berlie, Pharm.D. CDE, BCACP
Clinical Assistant Professor, Pharmacy Practice
Wayne State University
Detroit, MI

Ambulatory Care Specialist - Diabetes
Health Centers Detroit Medical Group
Detroit, MI

Senior Editorial Advisor

Gerard Hatheway, PharmD, PhD

Editorial Advisors

Belinda M. Danielson, RPh
Christopher M. DeSoto, PharmD
Angie S. Graham, PharmD
Cynthia Chan Huang, PharmD, MBA
Fred Plageman, PharmD

Editorial Advisor and Clinical Practice Consultant for Nurse Practitioners

Emily K.
Meuleman, RN, C, MS

About the Rx Consultant

The Rx Consultant is a monthly publication dedicated to providing health care professionals with the information they need to educate patients about drugs and manage drug therapy. The reader is responsible for confirming the information presented here and interpreting it in relation to each patient's specific situation before utilizing the information.

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