Psychiatric medication and abnormal behavior as predictors of progression in probable Alzheimer disease

Objective: To examine whether the use of psychiatric medication and the pre sence of abnormal behaviors affects the progression of Alzheimer disease. Design: Cross-sectional with longitudinal follow-up and the likelihood of a rriving at 4 end points: (1) Mini-Mental State Examination score of 9 or lo wer; (2) Blessed Dementia Rating Scale score of 15 or higher for activities of daily living; (3) nursing home admission; and (4) death, evaluated usin g a proportional hazard model with 9 variables: psychosis, insomnia, wander ing, aggression, psychomotor agitation, depression, and use of antidepressa nts, antipsychotic agents, or sedatives/hypnotics. Setting: Multidisciplinary dementia research clinic. Patients: We examined baseline and follow-up behavioral symptoms and the us e of psychiatric medication in 179 mildly to moderately impaired patients w ith probable Alzheimer disease participating in a longitudinal study of dem entia. Patients were observed from 2.4 to 172 months (mean duration +/- SD, 49.5 +/- 27.4 months). Results: Nine patients (5%) were taking sedatives/hypnotics ; 16 (9%), anti psychotic agents; and 22 (12%), antidepressants at study entry. Patients la king antipsychotic agents had lower Mini-Mental State Examination scores an d higher Blessed Dementia Rating Scale scores for activities of daily livin g than patients not taking any medication. Using proportional hazard analys is with time-dependent covariates for individual psychiatric symptoms and m edications, we found that the development of psychosis was associated with functional decline (time to Blessed Dementia Rating Scale score of greater than or equal to 15), institutionalization, aggression, and agitation with functional decline after adjusting for age at study entry, education, Mini- Mental State Examination scores, and Blessed Dementia Rating Scale scores. Use of antipsychotic medication was associated with functional decline, and sedatives/hypnotics with death. Neither the presence of psychiatric sympto ms nor use of medication was associated with rate of cognitive decline (tim e to Mini-Mental State Examination score of less than or equal to 9). Conclusions: These findings indicate that the use of antipsychotic agents a nd sedatives can affect the natural course of Alzheimer disease. Psychosis, agitation, and aggression are important predictors of outcome, even when t he effects of medication to treat them is taken into account.