Experts Stress Value of Integrated Care for Patients With Alzheimer's Disease

Neuropsychiatric symptoms are a challenging and pervasive aspect of Alzheimer's disease (AD) that affect up to 90% of individuals over the course of the illness. These issues, which may include depression, anxiety, agitation, delusions and sleep disturbances, can profoundly affect the quality of life of both patients and their unpaid family caregivers.

Although cognitive decline is the most recognized feature of AD, it is the neuropsychiatric aspects that frequently define the daily experience of patients and their families, explains psychologist Lucille Carriere, PhD, Behavioral Health Director at Cleveland Clinic. In fact, caregivers consistently rank neuropsychiatric symptoms as more distressing to manage than intellectual impairment or functional loss.

“My colleagues and I have witnessed how neuropsychiatric symptoms — from depression, anxiety, and agitation to psychotic features like delusions and hallucinations — can create significant disruptions in the lives of patients and their caregivers,” Dr. Carriere says. “Because they can profoundly compromise patients' quality of life, increase caregiver burden and elevate the risk of institutionalization, these problems must be addressed effectively.”

Path to treatment

As AD progresses, agitation and aggressive behaviors become more common – likely the result of damage to the brain’s emotional regulation centers and the impact of external stressors on patients with a diminished capacity for coping.

“Neurochemical imbalances, structural shifts in the brain, and inflammatory responses may all contribute to these symptoms,” explains Cleveland Clinic psychiatrist Kasia Gustaw Rothenberg, MD, PhD. “Depression and anxiety in AD, for instance, can be psychological responses to functional decline, but they’re rooted in neurochemical changes that disrupt normal emotional processing.”

Given the scope of neuropsychiatric symptoms in those with AD, nonpharmacological and behavioral strategies are widely regarded as the initial line of treatment. Central to the success of these therapies, Dr. Rothenberg says, is patient-centered care and an ongoing collaborative relationship with patients and their caregivers.

“By focusing on each individual’s unique needs, preferences and history, clinicians can create a supportive environment that alleviates the disease’s most distressing symptoms and improves the patient’s quality of life,” she says.

Dylan Wint, MD, Director of the Lou Ruvo Center for Brain Health at Cleveland Clinic Nevada, also stresses the importance of caregiver education when managing patients with AD.

“It’s essential for caregivers to avoid taking the patient’s behaviors personally, but those shifts in perspective can be difficult to achieve on your own,” he says. “I encourage providers to remind caregivers that neuropsychiatric symptoms are part and parcel of the syndrome called dementia; when cognition is impaired, we can expect behavior to be impaired as well. It can also be helpful for caregivers to understand that many of these distressing behaviors arise from confusion and fear.”

To minimize the suffering neuropsychiatric symptoms can provoke, Drs. Carriere and Rothenberg outline several additional therapeutic strategies:

Behavioral strategies and psychosocial support – When adapted for patients with AD, structured behavioral techniques like redirection and reassurance can help mitigate distressing behaviors and enable caregivers to apply adaptive coping strategies.

Environmental modifications – Changes to the patient’s physical surroundings, including a reduction in stimuli, may significantly decrease confusion and frustration. For example, reducing background noises, improving lighting and maintaining consistent routines can promote independence and help patients feel less anxious.

Sensory stimulation and relaxation techniques – Sensory interventions, including music therapy, aromatherapy and tactile stimulation, may have calming effects that can reduce agitation and aggression.

Exercise and physical activity – Regular physical activity, such as walking, tai chi or chair-based movements, can support physical fitness, healthy sleep rhythms and emotional wellness.

Reminiscence therapy and life review – Reminiscence therapy encourages patients to discuss past experiences using familiar objects, music or photographs. Dr. Carriere notes that this approach can strengthen the patient’s sense of identity, reduce depression and agitation, and foster connections with caregivers.

Engagement in meaningful activities – By participating in creative, stimulating activities that reflect their interests and hobbies, patients can regain their sense of purpose and achieve better symptom control. Massage and touch therapy have also been shown to reduce agitation and depression in patients with AD.

Pharmacological approaches

Although the advent of monoclonal antibodies is a critical advancement that may help slow early cognitive decline and disease progression, Dr. Rothenberg stresses that the persistence of neuropsychiatric symptoms necessitates treatment strategies that encompass both the physiological and psychological aspects of AD.

“A comprehensive care model that includes both monoclonal antibody therapies and a robust approach to care is essential,” she says. “Neuropsychiatric symptoms, which are rooted in complex neurobiological processes and exacerbated by environmental and psychosocial factors, require an ongoing, integrated treatment model that combines disease-modifying therapies with symptom and behaviorally focused care.”

Although antidepressants, including selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, are commonly prescribed to manage depression and anxiety in patients with AD, severe symptoms like agitation and psychosis may require treatment with atypical antipsychotics.

In addition, cholinesterase inhibitors and NMDA receptor antagonists, including donepezil and memantine, are frequently used to enhance cognitive function in patients with moderate to severe disease. Dr. Wint notes that cholinesterase inhibitors may also help reduce apathy, another common neuropsychiatric manifestation of AD, and indirectly improve neuropsychiatric symptoms by enhancing overall brain function.

He adds that these targeted medications should be prescribed sparingly and purposefully and monitored closely to ensure efficacy and safety.

Creating a new model of care

Ideally, says Dr. Rothenberg, neuropsychiatrists and psychologists should work collaboratively to deliver care that goes beyond the disease’s biological aspects by honoring each patient’s dignity, preferences, personhood and caregiver team.

Employing an integrated care model that relies on both psychological interventions and neuropsychiatric symptom management can enable clinicians to provide patients and their caregivers with meaningful relief, Dr. Carriere says.

“By creating a therapeutic pathway that addresses the physical, emotional and social dimensions of the disease, we can provide person-centered care that emphasizes safety, quality of life and respect for patients and their caregivers,” she adds. “The chief goal is to foster a healing environment in which dignity, comfort and emotional security are paramount.”