Conference Coverage

Agitation in Alzheimer Dementia: Progress for an Age-Old Problem


In this video, Craig Chepke, MD, DFAPA, and Kevin Williams, MS, MPAS, PA-C, provide the take-home messages from their session “Agitation in Alzheimer’s Dementia: Progress for an Age-Old Problem” at our Practical Updates in Primary Care 2023 Virtual Series. Dr Chepke and Mr Williams talk about how physicians can property diagnose agitation in patients with Alzheimer dementia, the optimal management of the disease, and the treatment options available for agitation, including the new FDA-approved treatment.

Kevin Williams, MS, MPAS, PA-C, is the CEO and lead clinician OnPoint Behavioral Health (Tampa, Florida).

Craig Chepke, MD, DFAPA, psychiatrist and medical director at Excel Psychiatric Associates (Huntersville, North Carolina).

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Kevin Williams, MPAS, PA-C: Hello, my name is Kevin Williams, a physician assistant in psychiatry here in Tampa, Florida.

Craig Chepke, MD, DFAPA: And I'm Dr Craig Chepke, a psychiatrist in Medical Director of Excel Psychiatric Associates in Huntersville, North Carolina, as well as an adjunct associate professor of psychiatry at Atrium Health.

Kevin Williams: Dr Chepke and I would like to thank you for joining us in our session today, and we wanted to remind you of some of our key learning points. First, in understanding the condition and screening, remember, the agitation and psychosis are the most prevalent symptoms of dementia. Next, we have that rippled effect with agitation on the person themselves, care partners, the community, and society as a whole. Then, recalling that we have a variety of assessment tools that assist us with screening and appropriately diagnosing agitation in Alzheimer dementia. Next, when we consider for optimal management, we, as providers, should really answer some of those common topics, which include identifiable behaviors, common triggers, and then what are those resulting consequences.

Also, we should facilitate in educating our care partners on the non-pharmacologic interventions, along with measuring their success in our individual patients. Lastly, we have to ensure that we enhance our communication between the providers, the patient, the care partners, because that helps to facilitate that optimal shared decision making.

Dr Chepke: That's right. And because agitation is the most common of the behavior and psychological symptoms of dementia, we need to act upon it because it does make a substantial difference in the life of not just the person, but the family and others in the sphere of those with agitation in Alzheimer dementia.

Now, as Kevin taught us very well in today's program, non-pharmacologic approaches are always the first line in agitation in Alzheimer dementia. But when pharmacotherapy is indicated, I did take us through an algorithm that has been recently released, which for people who are having moderate to severe, non-emergent agitation in Alzheimer, it is recommended that antipsychotics that are atypical antipsychotics are the first line treatments.

Now, the guidelines, as I mentioned, did not give any sort of preference to any specific antipsychotic in that algorithm, but they were published prior to the recent approval of brexpiprazole for agitation in Alzheimer dementia. And given that approval, I think that establishes it as a first line treatment because we do have the efficacy, safety, and the guidelines as to how to dose, what to expect with treatment when it has that FDA approval.

And brexpiprazole makes sense as we talked about in the program as a treatment for agitation in Alzheimer because it does have a strong and balanced binding affinity for the three monoamine neurotransmitters that when I talked about the neurobiology that we think underlies agitation in Alzheimer's, that we think leads to some of that pathology, the norepinephrine, serotonin, and dopamine malfunction that can occur in AADE. So, we're very fortunate now that we do have an FDA approved treatment, but no treatment will ever work for everybody so when that doesn't work, we had today a run through a variety of different other options that may be managed for our patients when that is going to be necessary for them.

So, we want to thank you for logging in to today's session and hope you have a great day.