Sink et al evaluated the management of neuropsychiatric problems seen in patients with dementia. The authors are from Wake Forest University and the University of California at San Francisco.


The management algorithm is given as a flow diagram in the Figure on page 606.


Steps in process:

(1) description of the dementia and problematic behavior

(1a) type of behavior

(1b) modifying factors (triggers, things that cause improvement, etc)

(1c) stakeholders (including the patient)

(1d) underlying type of dementia (especially presence or absence of dementia with Lewy bodies)

(2) evaluation for contributory factors (delirium, pain, drugs, environmental factors et al)

(3) nonpharmacologic management

(4) therapy for depression and/or anxiety

(5) therapy with cholinesterase inhibitor with or without memantine

(6) therapy with atypical antipsychotic medication (except in patient with dementia with Lewy bodies, who may develop the neuroleptic malignant syndrome).

(7) therapy with carbamazepine if other measures have failed to make an improvement



• A problem behavior in a demented patient is often considered part of the dementia process. Sometimes that patient's response is appropriate and will reverse if a cause is corrected.


After each intervention:

(1) monitor how the patient responded to the intervention

(2) monitor for adverse effects

(3) monitor for recurrence or progression in problematic behaviors


If a reasonable attempt at control of the behavior has failed, then it is appropriate to refer the patient to a specialist.


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