Psycho-behavioural disorders

So after memory disorders, after other cognitive disorders, we’ll now look at psychobehavioural disorders. We have to deal with these because they are important. They are a turning point in the disease. They are interdependent, they are associated with each other, and their frequency increases as the disease progresses. We’ll see that it is very important to show patience, not to act too quickly to these behavioural problems. They require appropriate treatment, primarily non-medical. A lot of expertise is required to deal with these behavioural disorders, they are real problems. They have significant consequences: risk of exhaustion among caregivers and carers, risk of abuse or neglect, worsening of the disease’s functional prognosis, risk of inappropriate drug prescription, and increased risk of hospitalisation. It is a turning point in Alzheimer’s disease for all these reasons. This is a classification system which I think can be useful for categorising these behavioural disorders. They may be affective or emotional, first and foremost apathy and anxiety. We’ll cover that later. 

They can be abnormal motor behaviours encompassing agitation, aggressiveness, compulsion, counting aloud, repetitive movements, etc. or a loss of inhibitions. A little later, as the disease evolves, they can become more like psychotic behaviours with hallucinations, delusions, issues with identification, perceptual disorders. Finally, there may also be basic behavioural disorders, sleep disorders, eating disorders or sexual disorders. So let’s look at the frequency of these psychobehavioural disorders during the disease. The most frequent disorder is apathy. This is an opportunity to explain what apathy is. Apathy, as you know, is a kind of overall reduction in activity. Patients often sit in an armchair and stop doing what they used to do. It can be very worrying for families, paradoxically, because, to a certain extent, the patient isn’t actually doing very much. 

You’d think that the patient’s state would be easy to deal with because families could have a rest. But it’s not reassuring. They worry because they say, “but that’s not who he is. He was active before, but now he does nothing. Why?” And this is often interpreted as a sign of depression. They think that the person is depressed because they no longer do anything. I usually ask the patient directly and say, “Are you sad?” Are you depressed? Are you unhappy?” And most often, patients with apathy do not express feelings of depression. 

There is a primary apathy in Alzheimer’s disease. That apathy is linked to the damage in regions which involve the impulse to do things. Patients with this disease have lesions in this region and no longer feel the need to get up and do things. So apathy – one of the most important elements in Alzheimer’s disease – should not be seen as a sign of depression in the patient. Depression does occur among these patients, but I think it is a little overestimated. 44% seems a bit high. There is a lot of anxiety, there may be restlessness, irritability, delusions. And there may be hallucinations, but those are fairly uncommon and more likely to occur when the disease has fully evolved. 

Here, there is the distribution of these psychobehavioural disorders based on the stage of the disease. In the early stages, the disease brings anxiety, depression, then apathy, and then finally, you see the slightly more psychotic elements with irritability, agitation, delusions and hallucination for a lower MMSE, at 18. MMSE is a score, a sort of cognitive state thermometer, which ranges from 0 to 30. You and I probably have a score of around 30. In Alzheimer’s disease, the MMSE during the initial stage is greater than 20. Below 20 it is already a disease, probably dementia, at dementia stage. And then the further down it goes, the more severe the damage. 

What should be done? The first thing is to eliminate is comorbidity. Geriatricians really insist on this, they say that when a patient is agitated, it is because there is perhaps, it is the person’s way of expressing their discomfort, their unhappiness. And the cause of this discomfort must be found: a urinary infection, with metabolic disorders in humans, pain which is poorly expressed, which results in agitation, irritability, apathy, dehydration, decompensation of a chronic pathology, etc. Also remember to consider iatrogenic conditions, because medications can have harmful consequences, for example there are antidepressants which cause hallucinations, etc. 

Don’t forget about abuse. Agitation can be a sign of that, and you need to be extremely vigilant and consider that. Finally, know how to wait, like I said at the beginning. There are some techniques depending on the person and the situation, for example active listening, encouraging the person to express themselves, diverting attention, stimulating the senses, adapting the environment, avoiding under-stimulation, isolation or, on the contrary, over-stimulation, noise, brightness which can be responsible for a state of anxiety in a patient who does not understand what is happening around them. Recording the voices of loved ones talking about positive memories can be useful, it’s reassuring. Reminiscence, reminding the person about memories that improve their self-esteem. 

Finally, affective touch, communicating comfort through touch. If the person is willing, obviously. These are some ideas. But these behavioural disorders, as you have understood, usually occur during a fairly advanced phase. They are observed at the dementia stage. You have to look at what else is happening. What do these behaviours mean? Are they trying to say something that the patient has difficulty expressing other than through agitation, anxiety, etc.? At the end of the day, there is something that we doctors are used to experiencing. 

It’s what we call sundowning, a feeling of unease and anxiety that patients usually experience at the end of the day, at sunset, the change in brightness inside their house. Something about this bothers them and there are often quite disturbing phases of anxiety. It’s a good idea to give them a little medication to sedate them somewhat. These are the basic behavioural disorders. We’ve looked at memory disorders, cognitive disorders and behavioural disorders. We have now seen all the disorders observed during Alzheimer’s disease.