When Should Antipsychotics for the Management of Behavioral and Psychological Symptoms of Dementia be Discontinued?

Affiliations: Palliative Care, Baycrest Geriatric Healthcare System, Toronto, Ontario, Canada; University of Toronto, Ontario, Canada

Abstract: Dementia in the older population is increasingly common, with many of these individuals requiring care in assisted living facilities or long-term care facilities. Others can be cared for at home with substantial support mechanisms. Regardless of setting, the behavioral and psychological symptoms of dementia often cause significant disruption and discordance between those experiencing the symptoms and their caregivers, other patients and residents, and family members. The use of antipsychotics in such situations and settings is common; however, these medications have many untoward side effects. In this article, the author discusses the possibility of lowering the dose of these medications with an ultimate goal of discontinuation, even in those deemed “stable” recipients of this class of medications.

Key words: Antipsychotics, behavioral and psychological symptoms of dementia, BPSD, neuroleptics.
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With the number of elderly persons increasing, including those living with dementia, the challenges of providing optimal care is a great challenge to policymakers and frontline practitioners, as a variety of medical, psychosocial, community-based, and institutional factors need to be carefully considered. This is particularly true when the behavioral and psychological symptoms of dementia (BPSD) manifest, which often leads to the use of antipsychotic medications (also known as neuroleptics) as a means of calming the patient and relieving their agitation and apparent suffering, while ensuring the safety and security of those around them and enabling healthcare professionals to provide proper care. Although these medications are sometimes necessary, clinical evidence and research generally advocates weaning individuals with BPSD off these medications. This article outlines two prototypical case studies that exemplify how discontinuation of these treatments can be beneficial in some cases, as well as a third case that shows the need to continue the medication in others. Following these cases, the use of antipsychotic medications for BPSD is reviewed, including the benefits and drawbacks of using these agents and factors that healthcare providers need to carefully consider.

Case 1: Successful Weaning Off an Atypical Antipsychotic

JS is an 87-year-old man with a 3-year history of gradual but progressive cognitive decline. He initially responded well to donepezil and a supportive home environment, where a devoted wife cared for him; however, she refused to accept external help to share the challenge of his care and gradually became overwhelmed by the “36-hour–like” day. This prompted her to explore the possibility of enrolling him in social programs run by a nearby seniors agency for those with dementia, but he expressed reluctance and she decided that she did not want to “move him” around from day to day. As JS’s word-finding became an issue and his speech became hesitant, he proceeded to become periodically agitated. Subsequently, his primary care physician prescribed small doses of risperidone, which led to less frequent outbursts.

With the support of her children and a social worker from a geriatric center, JS’s wife hesitantly agreed to employing a personal support worker (PSW) for 4 hours a day to help with his personal care and to enable her to “get out of the house” for a few hours and to run errands. She also agreed to enroll him once a week at the seniors’ program she had previously investigated to see if it would be appealing to him and give him “something to do” other than being home alone with her and the PSW. He seemed to enjoy the program, and the staff noted that he began to participate in some of the activities and to engage others in conversation, which was something he had not done for quite a while as his cognitive impairment progressed. In addition, many in the program recognized him, as he had been in business for many years in the neighborhood, and this recognition became a source of enjoyment for him.

On a follow-up clinic visit, it was apparent that he was somewhat stooped over when he walked. There was also less spontaneous facial expression and evidence of bilateral cogwheel rigidity, but his gait was still reasonable despite his turning being slow. A review of previous physical examinations did not show evidence of parkinsonism. His wife was somewhat concerned about his “slowing up,” but she was relieved by the improvement in his behavior, which she attributed to both the risperidone and the full-time PSW.

After a discussion that involved weighing the potential risks and benefits of decreasing the risperidone and perhaps discontinuing it altogether, she decided to proceed with gradually decreasing the dose and monitoring his gait, mobility, and the fluidity of his movements against his behavior. Over a 2-month period, JS was gradually weaned off the medication with no recurrence of his behavioral outbursts and an improvement in his flow of speech, gait, posture, and facial mobility.

Case 2: Successful Weaning Off a Conventional Antipsychotic

ND is a 91-year-old man who was admitted to a nursing home from his home, where his wife had cared for him with the assistance of a full-time PSW. When she died, ND’s children decided to keep him at home, but he became increasingly withdrawn and noncommunicative. A month after his wife’s death, ND was admitted to a general hospital because of an infection, which turned out to be from his urinary tract. While hospitalized, he became highly confused and agitated. He was treated with haloperidol parentally and then put on oral doses of the same medication, which seemed to calm him down. His infection responded to antibiotic treatment and he was discharged to home with medications to address his prostatic hypertrophy and incomplete bladder emptying.

He appeared comfortable at home, but his children noted that he was far less communicative than before his hospitalization. Despite having received a dementia diagnosis several years earlier, his level of function and communication had been such that he could perform his basic activities of daily living with minimal help. Although his speech was often repetitive, he was able to recount important stories of his life, especially to his youngest daughter; thus, she became particularly upset by his loss of communicative skills and lack of social engagement following his acute hospitalization for the infection.

After he was settled in the nursing home, she brought up her concerns about the changes that occurred, especially his loss of interactive and communication skills and interests, which were the symptoms that precipitated the decision to admit him to the nursing home. This decision was made partially for care and partially to ensure he was in a safe environment that provided a range of social and stimulating activities. She was disappointed that her father did not seem to be particularly engaged or interested in the recreational activities available. When she spoke to the physician about her concerns, the possibility of depression was discussed, with the potential to add antidepressants to his medication regimen, which still included the haloperidol prescribed more than a year earlier during his acute care hospitalization.

Instead, a geriatric consultation was sought. After the evaluation, rather than introducing another psychoactive drug, the decision was made to gradually decrease the dose of haloperidol, with a goal of discontinuing it altogether if feasible. Over a 2-month period, the medication dosage was decreased in small increments weekly until the dose was so low that it was discontinued. This process resulted in improvement in the patient’s affect and engagement levels. Antidepressants were not added to his regimen. After 3 months, the patient was more animated and the daughter told the geriatrician during a follow-up meeting, “You gave me my father back.”

Case 3: Unsuccessful Weaning Off an Atypical Antipsychotic

EL is an 87-year-old woman who was being followed in a geriatric medicine clinic for 1 year. She had a diagnosis of schizophrenia, although the details of her earlier mental status were not clear from her family. For the previous 9 years, she had evidence of moderate dementia with increasing BPSD. She was receiving donepezil for her cognition issues, which the family felt had benefitted her and initially helped with her BPSD; however, she had been titrated to quetiapine to better control the BPSD, with the most recent maintenance dose being 50 mg at bedtime and 37.5 mg in the morning. She seemed to tolerate this regimen well and was reasonably stable, but was occasionally drowsy during the day.

After a geriatrician consulted with the family, the decision was made to lower the dose of quetiapine, with a goal of weaning the patient off it completely. This recommendation was made to the primary care physician, who began to gradually decrease the medication. For the first 3 weeks during the process, there were no discernible problems. Thereafter, EL became somewhat agitated, but the physician continued to decrease the dose based on the assumption that she would eventually manage without the medication. By the time she had a follow-up appointment at the geriatric clinic, which occurred 3 months after the dose was discontinued altogether, the family reported that she was severely agitated and began to experience hallucinations, which had not occurred while she was on the neuroleptic medication.

Attempts were made to calm EL down by reintroducing the quetiapine, gradually increasing the doses, and adding trazodone to help with her sleep. Because the family became unable to carry on with home care due to her BPSD, she was admitted to the geriatric psychiatry unit. After 2 months of readjusting her psychoactive medications, her BPSD gradually became adequately controlled, enabling her to be discharged to home on a slightly higher dose of the neuroleptic than she had received prior to the attempt at discontinuation.

Discussion

Any practitioner who cares for geriatric patients, particularly those living with dementia, has to grapple with the use of antipsychotics for managing behavioral issues, regardless of whether the patient is in the community, an acute care setting, or in long-term care (LTC). There are two classes of antipsychotics that can be used: conventional antipsychotics (also known as typical antipsychotics), which are first-generation agents that were first developed in the 1950s to treat psychosis; and atypical antipsychotics, which are second-generation agents that emerged in the 1980s.¹ Both types have similar mechanisms of action and block receptors in the brain’s dopamine pathways. For many years, atypical antipsychotics were thought to be safer and cause fewer extrapyramidal neurological effects; however, as their use has increased, more side effects have been observed, leading some to question whether there should be a distinction between these first- and second-generation agents.¹ Regardless, none of these agents has been approved by the US Food and Drug Administration (FDA) to manage BPSD, and they are prescribed off-label for this purpose.

When antipsychotics are prescribed, it is typically to prevent the patient from inflicting self-harm and/or harm to others, while enabling healthcare professionals and caretakers to provide necessary care. In addition to the scenarios described by the aforementioned cases, a variety of other factors can trigger behavioral problems in older people with a known underlying cognitive impairment and necessitate the use of antipsychotics. These factors include infections, surgery, changes in medication, and any other acute medical insult, as these can also lead to delirium, which may not always be readily identified.² In such cases, if the patient’s condition responds to these agents, they may be continued whether the patient moves into an LTC facility or returns to the community with personal care support. Yet as case 1 and case 2 demonstrate, slowly weaning patients off these medications may be beneficial, and there has been a push by various regulatory and authoritative bodies to limit antipsychotic prescribing for BPSD.

Major Measures to Decrease Antipsychotic Prescribing in Long-Term Care

There has been a shift away from the use of antipsychotics in the treatment of BPSD, especially in the LTC setting. In the United States, the Omnibus Budget Reconciliation Act of 1987 (OBRA), which limited the use of psychotropic medications in LTC residents, appears to have achieved much of its desired effects. Although updates of OBRA guidelines have liberalized some dosing restrictions, the 2007 iteration required gradual dose reductions of all antipsychotics in nursing home residents, with staff having to document at least two attempts to reduce these medications during the first year of treatment for newly admitted residents and for established residents initiated on these medications.³ In addition, if the drug is continued beyond the first year, gradual dose reductions must be attempted at least once annually unless contraindicated (eg, target symptoms worsened during most recent attempt at dose reduction).³

Other jurisdictions have used different methods to regulate antipsychotic medication use. For example, in the province of Ontario, Canada, the Coroners’ Committee on Geriatrics and Long-Term Care provides recommendations aimed at reducing harm and unnecessary deaths among elderly patients receiving healthcare services.^4-6 A recent report of that committee recommended the following when addressing the issue of dementia and behavior: (1) Allied healthcare staff and physicians in LTC facilities should be provided with education on pharmacologic and nonpharmacologic management of BPSD; (2) Ministry of Health and LTC funding should be made available to LTC facilities to assist with the nonpharmacologic management of challenging behaviors, particularly after a resident’s admission to a new environment; and (3) All LTC facilities should have immediate access to outreach teams to assist with the management of BPSD or specialized behavior units to accept residents in transfer for more in-depth assessment and treatment.⁶

In 2008, the FDA required manufacturers to add a Boxed Warning to conventional antipsychotic drugs to warn about an increased risk of death associated with the off-label use of these agents to treat behavioral problems in older people with dementia.⁷ Previously, in 2005, the FDA required a similar Boxed Warning to be added to atypical antipsychotic drugs. Both warnings indicate that clinical studies have shown antipsychotic drugs to be associated with an increased risk of death when used in elderly patients treated for dementia-related psychosis.⁷ In fact, when the FDA decided to include the warning on atypical antipsychotic drugs, it reported that studies demonstrated a 1.6- to 1.7-fold increase in mortality with use of antipsychotics compared with placebo.⁸ The Table outlines the conventional and atypical agents included in the FDA’s action.

In 2012, the American Geriatrics Society (AGS) published its Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.⁹ These guidelines, which were developed by an interdisciplinary expert panel that reviewed the literature to identify adverse drug reactions (ADRs) in older patients, advise against the use of antipsychotic medications to treat BPSD, noting that they can cause adverse central nervous system effects and increase the risk of stroke and mortality in these patients. Therefore, per the guidelines, they should be avoided unless nonpharmacological options have failed and the patient is a threat to himself/herself or others. This recommendation was based on high-quality evidence and is categorized as strong.⁹

The Centers for Medicare & Medicaid Services (CMS) also launched an initiative in 2012 to curtail the use of antipsychotics to manage BPSD in US nursing home residents.¹⁰ This initiative set a national goal to reduce off-label antipsychotic use by 15% by December 31, 2012. As part of the initiative, CMS developed a multidimensional action plan that focused on public reporting, public awareness, regulatory oversight, technical assistance/training, and research. One training tool it developed specifically for nursing homes is its “Hand in Hand” program, which teaches staff how to employ nonpharmacological alternatives in caring for patients with BPSD.

Perceptions of Antipsychotic Use in Long-Term Care

With the preponderance of data recommending against the use of antipsychotics for BPSD and numerous warnings of their ADRs, there is a tendency for these agents to be viewed negatively. Yet they can be beneficial in some patients, as shown by the case 3 patient, who experienced negative effects when these agents were discontinued, which led to the inability of her family to continue to care for her in the community. After the antipsychotic was reinstated, she was able to return home to her family, improving her quality of life. Even the AGS’s Beers criteria, which recommend against using these agents, acknowledge they may be necessary if the BPSD has become so severe that the patient poses a safety risk to himself/herself or to others.⁹ This stance is in agreement with numerous published reports that note that these agents may be deemed clinically necessary during states of acute delirium or when behavioral manifestations of dementia become severe.^11-15 Therefore, the motivation to use such drugs or continue them is not always sinister.

Nevertheless, a message that often resurfaces in the popular press, which is reflective of contemporary medical reporting, is the notion that even when the initial indications for the use of antipsychotics have been reasonable and correct, a bad outcome necessitates extreme measures, from establishing special medication units for those with risky behaviors to eliminating psychoactive medications from the LTC landscape altogether. During such events, unhappy family members, the media, and certain healthcare professionals who oppose the use of these medications may imply that the antipsychotic was used simply as a “medical restraint” to reduce the staff’s workload. In some situations, healthcare professionals who have never worked in LTC facilities are asked to comment on these cases, and these individuals rely on the literature to support their antineuroleptic positions. In contrast, most physicians experienced in geriatric care understand that although these medications may be characterized as “medication restraints,” this characterization does not paint a fair and complete picture of the role of these agents.

Another factor that often leads to medications being denigrated is off-label status, as is the case when using antipsychotics for BPSD; however, it is important to consider what “off-label” really means. For many medications, the trials that enabled them to be approved focused on one particular condition; however, over time, clinical assessments and scholarly papers outlining successful clinical experiences with these agents for other conditions have led their use to be expanded by the medical community, despite these indications not being included in the drugs’ official prescribing information.¹⁶ It is essential for healthcare providers to remember that many medications are used successfully for indications that have not been specifically approved by the FDA. For example, angiotensin-converting enzyme inhibitors are now often used in patients with diabetes to decrease their risk of renal disease, which is in keeping with the medical research literature, despite the absence of a specific formal FDA indication for that use.^16-18

On the other hand, when some healthcare providers who prescribe antipsychotics for BPSD witness an amelioration of frightening and disruptive neuropsychological behaviors upon administering these agents, they may be reluctant to wean these patients off these medications. Yet as case 1 and case 2 show, these agents may only be needed temporarily in some patients, and slowly discontinuing these treatments may improve these individuals’ quality of life.

Principles of Instituting and Tapering Antipsychotics

Putting aside the off-label designation and the literature that shows antipsychotics to have negative effects, there is also literature to support the use of these agents in the care of some older patients when their agitation or aggression is due primarily to their dementia, rather than to another confounding factor, such as uncontrolled pain.^12-15 In such situations, a trial of a neuroleptic within a process of titration to match the clinically positive benefits versus the negative aspects of their use is not unreasonable; if fact, in some situations this is absolutely necessary to avoid serious self-harm or harm to others. The key to this process is the acknowledgement of a parallel plan that undertakes the gradual decrease in dosage after some degree of stability is achieved for a reasonable period of time.^12-15 Until the literature better defines this period, 3 to 6 months may be reasonable to start with. During this time, the patient should be carefully evaluated for clinical stability and evidence of any untoward side effects, such as gait issues, somnolence, and parkinsonian symptoms.  

With this process, it is hoped that any factors that induced or perpetuated the agitation or aggressive behavior will also have been addressed and resolved, such that the environment is as suitable and conducive as possible for a trial of decreasing the dosage. If the gradual decrease in dosage proves successful, a further trial of discontinuation is warranted, during which careful monitoring of the clinical and behavioral situation is undertaken using reports from medicine, nursing, social work, recreational therapy, and the family, particularly if the person is in an LTC or assisted living environment.

There are no hard and fast rules regarding the tapering process; however, because antipsychotics are often substantially fat-soluble, they are stored in the body, and any changes in dose will take time before the actual blood and tissue levels reach a new equilibrium. Subsequently, it takes time to observe a therapeutic impact. Although geriatric medicine generally recommends a prescribing approach that starts low and goes slow, this should be implemented in reverse with regard to antipsychotics: go slow as you start to go low. For example, the dose could be decreased by one-quarter per week, with the goal of weaning the patient off the drug in 4 to 6 weeks. Such a slow titration enables the healthcare provider and caregivers to observe how the change in dose is affecting the patient. If untoward effects are observed, there is a chance to push the dose back up from a reasonable level, rather than having to titrate upwards all over again, as occurred with the patient in case 3.

Optimizing Outcomes With Nonmedication Interventions

To ensure the safety and optimal function of patients with BPSD, as well as to protect those around them, it is often clinically crucial to use behavioral and environmental interventions in addition to medication interventions. Over the years, many nonmedication interventions have been found to be beneficial in defusing behavioral manifestations of dementia, including a variety of sensory interventions (eg, aromatherapy, thermal bath, calming music, massage) and pet therapy.^19-25 In addition to curtailing disruptive behaviors, these interventions may also improve the quality of life of those affected. For example, a study that examined animal-assisted therapy for nursing home residents with BPSD found that this intervention also increased the residents’ level of social interaction.²⁶

Some researchers have suggested that pain management may be effective in many individuals with dementia who are agitated by pain that is not readily identified because of an inability of this population to identify their symptoms accurately.²⁷ It is important for healthcare providers to remember that pain management starts with nonpharmacological approaches, including ensuring comfortable positioning and a peaceful environment while addressing lifestyle factors, such as sleep, diet, exercise, and social activities. In addition, many of the nonmedication interventions for BPSD may prove beneficial in pain reduction. When nonpharmacological approaches fail, analgesics can be considered.

Regardless of the methods used, the interprofessional healthcare team needs to be involved, and the entire team should be included in any education initiatives. These steps are important so that it is not only the physician who determines what methodologies may best suit the needs of the patient, the patient’s family, and those responsible for frontline care, as everyone in the team may have important insights to contribute.^19-25

Conclusion

The use of antipsychotics for the treatment and amelioration of BPSD is common practice across a wide range of care environments. The medications may be beneficial in achieving the goals of calming the person living with dementia’s disruptive and often disturbing symptoms. With the acknowledgment of the potentially negative short- and long-term adverse effects of this class of medications, it is often worthwhile to undertake a trial of decreasing the dosage, with a goal of discontinuing it altogether if the results are positive. During this process, carefully monitoring patient outcomes is essential. If the patient’s agitation or aggression increases during or after the weaning process, the antipsychotic may need to be reinstituted.

References

1.     US Department of Health & Human Services; Agency for Healthcare Research and Quality. First-generation versus second-generation antipsychotics in adults: comparative effectiveness. Published August 14, 2012. Accessed March 10, 2014.

2.     George J, Long S, Vincent C. How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions. J R Soc Med. 2013;106(9):355-361.

3.     Epstein-Lubow G, Rosenzweig A. The use of antipsychotic medication in long term care. Medicine & Health/Rhode Island. Accessed March 10, 2014.

4.     Colenda CC, Streim J, Greene JA, Meyers N, Beckwith E, Rabins P. The impact of OBRA ‘87 on psychiatric services in nursing homes. Joint testimony of the American Psychiatric Association and the American Association for Geriatric Psychiatry. Am J Geriatr Psychiatry. 1999;7(1):12-17.

5.     Snowden M, Roy-Byrne P. Mental illness and nursing home reform: OBRA-87 ten years later. Omnibus Budget Reconciliation Act. Psychiatr Serv. 1998;49(2):229-233.

6.     Ontario Ministry of Community Safety & Correctional Services. Reports of the Geriatric and Long Term Care Review Committee; Cases 2012-08, 2012-13, and 2012-18. www.mcscs.jus.gov.on.ca/english/DeathInvestigations/office_coroner/PublicationsandReports/GLTC/GLTC.html. Accessed February 1, 2014.

7.     FDA requests boxed warnings on older class of antipsychotic drugs [news release]. Silver Spring, MD: US Food and Drug Administration; June 16, 2008. www.fda.gov. Accessed March 10, 2014.

8.     US Food and Drug Administration. Public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. www.fda.gov. Published April 11, 2005. Accessed March 10, 2014.

9.     American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631.

10.   Centers for Medicare & Medicaid Services. Initiative to improve behavioral health and reduce the use of antipsychotic medications in nursing homes residents video streaming event. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Spotlight.html. Accessed March 10, 2014.

11.   Brodaty H, Ames D, Snowdon J, et al. A randomized placebo-controlled trial of risperidone for the treatment of aggression, agitation, and psychosis of dementia. J Clin Psychiatry. 2003;64(2):134-143.

12.   Bullock C. Antipsychotic medications can be reduced in treating patients with dementia. www.docguide.com/antipsychotic-medications-can-be-reduced-treating-patients-dementia. Published May 7, 2013. Accessed February 1, 2014. 

13.   Rayner AV, O’Brien JG, Schoenbachler B. Behavior disorders of dementia: recognition and treatment. Am Fam Physician. 2006;73(4):647-652.

14.   Desai AK, Grossberg GT. Recognition and management of behavioral disturbances in dementia. Prim Care Companion J Clin Psychiatry. 2001;3(3):93-109.

15.   Omelan C. Approach to managing behavioural disturbances in dementia. Can Fam Physician. 2006;52(2):191-199.

16.   Consumer Reports. Off-label drug prescribing: what does it mean for you? www.consumerreports.org/cro/2012/05/off-label-drug-prescribing-what-does-it-mean-for-you/index.htm. Updated December 2012. Accessed February 2, 2014.

17.   Ross HM. ACE inhibitors: blood pressure control in diabetes. https://diabetes.about.com/od/equipmentandbreakthroughs/a/aceinhibitors.htm. Published November 14, 2007. Accessed March 10, 2014.

18.   Skolnick A. Ramipril may help prevent cardiovascular events, diabetes among high-risk patients. www.diabetesclinic.ca/en/prof/6comp/ramipril_cvevents.htm. Published October 30, 2002. Accessed February 3, 2014.

19.   Sung HC, Chang AM. Use of preferred music to decrease agitated behaviours in older people with dementia: a review of the literature. J Clin Nurs. 2005;14(9):1133-1140.

20.   Sung HC, Chang SM, Lee WL, Lee MS. The effects of group music with movement intervention on agitated behaviours of institutionalized elders with dementia in Taiwan. Complement Ther Med. 2006;14(2):113-119.

21.   van der Ploeg ES, Eppingstall B, Camp CJ, Runci SJ, Taffe J, O’Connor DW. A randomized crossover trial to study the effect of personalized, one-to-one interaction using Montessori-based activities on agitation, affect, and engagement in nursing home residents with dementia. Int Psychogeriatr. 2013;25(4):565-575.

22.   Deudon A, Maubourguet N, Gervais X, et al. Non-pharmacological management of behavioural symptoms in nursing homes. Int J Geriatr Psychiatry. 2009;24(12):1386-1395.

23.   Viggo Hansen N, Jørgensen T, Ørtenblad L. Massage and touch for dementia. Cochrane Database Syst Rev. 2006;18(4):CD004989.

24.   Cohen-Mansfield J, Thein K, Marx MS, Dakheel-Ali M, Freedman L. Efficacy of nonpharmacologic interventions for agitation in advanced dementia: a randomized, placebo-controlled trial. J Clin Psychiatry. 2012;73(9):1255-1261.

25.   Cohen-Mansfield J, Jensen B, Resnick B, Norris M. Knowledge of and attitudes toward nonpharmacological interventions for treatment of behavior symptoms associated with dementia: a comparison of physicians, psychologists, and nurse practitioners. Gerontologist. 2012;52(1):34-45.

26.   Richeson NE. Effects of animal-assisted therapy on agitated behaviors and social interactions of older adults with dementia. Am J Alzheimers Dis Other Demen. 2003;18(6):353-358.

27.    Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ. 2011;343:d4065.

Disclosures: The author reports no relevant financial relationships.

Address correspondence to: Michael Gordon, MD, Baycrest Geriatric Healthcare System, 3560 Bathurst Street, Room 1C24, Toronto, ON, M6A 2E1, Canada; m.gordon@baycrest.org