Introduction: Patients affected by neurodegeneration disorders (NDD) often experience difficult to
treat disruptive neuropsychiatric symptoms (NPS) i.e. verbal disruption, aggression, psychomotor
hyperactivity, sleep difficulties, hallucinations, delusions. The existing treatment algorithms include
antipsychotics, gabapentin, trazodone, prazosin, memantine, cholinesterase inhibitors.1,2 Some
NPS i.e. anxiety, agitation, aggression, disturbed sleep have been linked to overactivity of the brain
noradrenergic system (NAS). The current report suggests a treatment algorithm which includes a method
of noradrenergic modulation (NAM). Aims of the study: A. To evaluate a new treatment algorithm
for patients with NPS and late life dementia. B. To evaluate the method of NAM in treatment of NPS.
Participants and Methods: Nine elderly community dwelling patients (3 males and 6 females) with
probable Alzheimer’s dementia and NPS. Age of the patients 71-104 years (86.9, SD 9.4), 4 patients with
moderate and 5 patients with severe dementia. Treatment algorithm includes 5 steps and two pathways.
Each step is evaluated on the clinical global impression of change (CGI-C) scale. The psychosis
pathway (4 patients) begins with an antipsychotic, the alternative pathway (5 patients), with low dose
gabapentin (GBP). The psychosis pathway, if ineffective, can switch to the alternative pathway with
the add-on of GBP. The alternative pathway proceeds with addition of NAM which includes alpha-1
receptor antagonists (prazosin, doxazosin) and alpha-2 receptor agonists (transdermal clonidine,
guanfacine). Results: Treatment was well tolerated. Substantial (7 patients) and moderate (2 patients)
improvement in disruptive behaviors such as agitation, aggression, sleep was reflected on the CGI-C
scale (score 1.2, SD 0.4), on the Cohen-Mansfeld Agitation Inventory (the score decreased from 52.6,
SD 27.0 to 18.6, SD 7.9) and on the de novo introduced VAPS scale (from 8.7, SD 0.4 to 2.7, SD 0.8).
The final step of the algorithm, method of NAM was the “game changer” in both psychosis and nonpsychosis alternative pathways. Conclusion: The case series provides preliminary evidence supporting
the suggested approach to treatment of NPS in patients with late life dementia
