Non-drug treatment options, such as behavioral techniques and environment adjustment, should be considered before initiating pharmacotherapy in older patients with behavioral deregulation caused by a neurocognitive disorder. Before considering any interventions, including medical therapy, an evaluation and development of a profile of behavioral symptoms is warranted.
The purpose of such a profile is to:
- guide a patient-specific treatment plan
- measure treatment response (whether medication-related or otherwise).
Developing a profile for a patient can lead to a more tailored treatment plan. Such a plan includes identification of mitigating factors for the patient’s behavior and use of specific interventions, with a preference for non-medication interventions.
Profile assessment can guide treatment
The disruptive-behavior profile that I created (Table) can be used as an initial screening device; the score (1 through 4) in each domain indicates the intensity of intervention required. The profile also can be used to evaluate treatment response.
For example, when caring for a person with a neurocognitive disorder with agitation and disruptive behavior, this profile can be used by the caregiver as a reporting tool for the behavioral heath professional providing consultation. Based on this report, the behavioral health professional can evaluate the predisposing, precipitating, and perpetuating factors of the behavioral disturbance, and a treatment plan can be implemented. After interventions are applied, follow-up assessment with the tool can assess the response to the intervention.
The scale can aid in averting overuse of non-specific medication therapy and, if required, can guide pharmacotherapy. This assessment tool can be useful for clinicians providing care for patients with a neurocognitive disorder, not only in choosing treatment, but also to justify clinical rationale.
How does this scale compare with others?
The Neuropsychiatric Inventory (NPI), Behavioral Pathology in Alzheimer’s Disease (Behave-AD), Cohen-Mansfield Agitation Inventory, and Brief Agitation Rating Scale provide valuable information for clinical care. However:
- Use of the NPI in everyday practice is limited; time spent completing the NPI scale remains a significant impediment for the busy clinician.
- Behave-AD requires a higher level of skill for some caregivers to estimate behavioral symptoms and answer questions about severity.
- Cohen-Mansfeld and Brief Agitation Rating Scale provide a limited description of the intensity of behavioral disturbance.
Developing a treatment plan and justifying pharmacotherapy in patients with a neurocognitive disorder is a challenge for clinicians. The scale that I developed aims to (1) assist the busy clinician who must construct a targeted treatment plan and (2) avoid pharmacotherapy when it is unnecessary. If pharmacotherapy is warranted on the basis of any of the domain scores in the profile, it should be documented with a judicious rationale.