Detecting and Managing Neuropsychiatric Symptoms in Dementia

This issue of the Canadian Journal of Psychiatry contains two review articles on the issue of neuropsychiatric symptoms of dementia. We welcome attention to this topic for two reasons. First, it is a reflection of the growing importance of seniors’ mental health and geriatric psychiatry as our population ages. Second, it provides general psychiatrists with concise and helpful information about recent developments and controversies in recognizing and treating neuropsychiatric symptoms in dementia. The disciplines of geriatric psychiatry and dementia care have been advancing quickly in the past five years. Subspecialty training in geriatric psychiatry was recognized in Canada in 2012, and since that time, 11 universities have opened formal geriatric psychiatry training programs in Canada. More than 180 psychiatrists—many of whom have been in practice for decades—have qualified with the new geriatric psychiatry subspecialty designation. Even so, we are currently at less than half of the benchmarks set by the guidelines for comprehensive services for elderly persons in Canada. In most of the country, geriatric psychiatrists remain a scarce resource. Therefore, there is still tremendous need for general psychiatrists across the country to provide expert assessment and management of patients with dementia, particularly as the population ages and the prevalence of dementia climbs. The first article in this issue reflects on the early presence of neuropsychiatric symptoms prior to the diagnosis of dementia and provides suggestions for using the symptoms as an opportunity for early diagnosis and intervention. The second article focuses on the problem of widespread antipsychotic use in patients with dementia, a topic of significant interest to any psychiatrist working with older people. Both of these topics are of importance to all psychiatrists. Gallagher, Fischer, and Iaboni argue that neuropsychiatric or behavioural symptoms, even in individuals with no or little change in cognitive functioning, can herald a neurocognitive disorder. This ‘‘precognitive’’ stage, with mood and sleep changes, anxiety, agitation, and apathy symptoms, is understood to have biological as well as psychological underpinnings. Pathological changes in the brain precede the onset of clinical dementia by decade or two. Neurodegenerative or vascular damage disrupts frontal-subcortical circuits in the brain, affecting drive, affect regulation, salience, perception, and impulse control. The regulation of emotion and behaviour is thus subtly altered as cognitive performance begins to slip. There is clearly value in considering whether late-onset psychiatric symptoms indicate the presence of a neurocognitive disorder. The prevalence of mild cognitive impairment (MCI) is about 18% to 35% in those older than 65 years. While the overall rate of conversion of MCI to dementia is around 5% per year, in those who are exhibiting neuropsychiatric symptoms, 25% will convert to dementia per year. Almost a third of people with dementia come to psychiatric attention prior to receiving a dementia diagnosis. However, vigilance for dementia must be balanced by the risk of mislabeling a primary psychiatric disorder as dementia, leading to the serious consequences of a neurodegenerative diagnosis when none exists in reality. For example, while individuals with late-life depression are at severalfold increased risk of dementia, most do not develop dementia. Likewise, as many as one-quarter of people with MCI will convert to ‘‘cognitively normal’’ within 1 year. As such, more study of the use of the new term mild behavioural impairment and its ramifications is warranted. In the