Neuropsychiatric Symptoms (NPS) and Neurocognitive Disorders

Nearly all patients with major neurocognitive disorder (MNCD, formerly dementia) or mild neurocognitive disorder (mNCD) will develop non-cognitive neuropsychiatric symptoms (NPS) at some point in the course of their disease. Clinicians of any discipline or medical specialty who treat geriatric patients will inevitably see patients with MNCDs and associated behavioral and psychological symptoms of dementia (BPSD). NPS may present in the prodromal phase of Alzheimer’s disease (AD) and other neurodegenerative disorders, and they often increase in frequency throughout the course of the illness. Comorbid depressive and psychotic disorders, among NPS, are associated with more rapid cognitive decline in AD. Given their enormous impact on quality of life, safety, function, caregiver burden, and cost of care, BPSD become the primary concern of family and caregivers. The demand for treatment of BPSD is significant: a cross-sectional analysis of Medicare claims in the United States in 2018 found that 13.9% of older individuals with MNCD filled prescriptions for CNS-active polypharmacy (Maust et al. JAMA 325:952–61, 2021). This chapter discusses an age-adjusted approach to NPS: ruling out modifiable contributors to MNCDs, treating systemic medical comorbidities, correcting environmental factors, and instituting non-pharmacological interventions as first-line interventions. A minimalist ethic endorses pharmacological treatment when it is needed for the management of disruptive or dangerous psychiatric symptoms but always with the goal of limiting risk of adverse effects.