In Reply

The Diagnosis and Treatment of Behavioral Disorders in Dementia by Prof. Dr. med. Torsten Kratz in issue 26/2017

I thank Dr. Bienentreu and Dr. Stein for their important comments regarding the drug treatment of behavioral disorders in dementia. In particular, their mention of the numerous adverse effects and interactions of drugs for behavioral disorders underlines the necessity of critically weighing up the risks and benefits and highlight the ensuring dilemma. In the present article, Table 2 (Problematic psychoactive drugs in the treatment of behavioral disorders in demented patients) provides relevant details on this, while also taking into account the PRISCUS list (1). Even though the guidelines (2) recommend treatment attempts using drugs, it makes sense to investigate somatic or environmental causes and treat those specifically before starting any such symptomatic treatment. In many cases, high risk medicinal treatment is then no longer needed. For this reason, my article focused on non-drug treatment approaches in the context of behavioral disorders in dementia. The effectiveness of non-drug based approaches can be superior to solely drug-based treatments. Treating agitation and aggressiveness with risperidone achieves an effect size of d = 0.33 (2, 3), whereas the use of occupational therapy achieves a greater effect size when used in apathy, restlessness, and agitation-namely, d = 0.72 (2, 4). My article was intended to point out that the global effect of non-drug-based therapeutic approaches on behavioral disorders has been proven. Because of the heterogeneity of the interventions, however, it is currently not possible to say which specific approaches should be used in which specific behavioral disorder. More research is needed in this setting. It is undisputable, however, that non-drug-based therapeutic approaches should be implemented more full scale into daily practice in care/nursing homes and hospitals, so as to improve the quality of life of those affected and their carers, and to avoid polypharmacy and its known risks.

DOI: 10.3238/arztebl.2017.0754a

Prof. Dr. med. Torsten Kratz
Abteilung für Psychiatrie, Psychotherapie und Psychosomatik
Funktionsbereich Gerontopsychiatrie
Königin-Elisabeth-Herzberge Krankenhaus, Berlin

Conflict of interest statement

Prof. Kratz has received lecture honoraria from Lilly and Janssen-Cilag.

References

1. Kratz T: The diagnosis and treatment of behavioral disorders in dementia. Dtsch Arztebl Int 2017; 114: 447–54

2. Deuschl G, Maier W, Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN), Deutsche Gesellschaft für Neurologie (DGN): Diagnose- und Behandlungsleitlinie Demenz – Interdisziplinäre S3 Praxisleitlinien 2016. www.dgn.org/images/red_leitlinien/LL_2016/PDFs_Download/038013_LL_Demenzen_2016.pdf (last accessed on 17 August 2017).

3. Chan WC, Lam LC, Choy CN, Leung VP, Li SW, Chiu HF: A double-blind randomised comparison of risperidone and haloperidol in the treatment of behavioural and psychological symptoms in Chinese dementia patients. Int J Geriatr Psychiatry 2001; 16: 1156–62

4. Gitlin LN, Winter L, Burke J, et al.: Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: a randomized pilot study. Am J Geriatr Psychiatry 2008; 16: 229–39