We often hear that one of the greatest challenges for clinicians is psychiatric problems in persons with dementia. Psychiatric illnesses can create difficulty with determining a person's cognitive level and best ability to function, and with identifying an appropriate treatment plan. But here is information to help you, as an Allen-trained therapist, address this often-seen comorbidity.

Psychiatric Symptoms of Alzheimer's

  • Sleep disturbance
  • Irritability, agitation
  • Emotional distress, anxiety
  • Restlessness, pacing
  • Delusions
  • Hallucinations

These symptoms may occur due to fear, an underlying medical condition, side effects of medications, changes in routine or the person's environment, feeling threatened, psychiatric illness, and/or changes in the brain that result in similar symptoms of psychiatric illnesses.

What medical conditions might create psychiatric symptoms in a person?

  • Pain
  • Infections
  • Sensory problems
  • Constipation
  • Medication interactions
  • Symptoms of specific diseases; e.g., Lewy Body disease

What social conditions might create psychiatric symptoms in a person?

  • Inability to express an unmet need
  • Loss of sense of self
  • Inappropriate expectations being placed on the individual
  • Boredom

Research indicates that up to 90% of the time, challenging behaviors (agitation, irritability, restlessness, sleep disturbance, and/or emotional distress) that occur in persons with dementia may be caused by either something in the environment or by a caregiver approach.

Depression: common signs and symptoms

  • Feelings of helplessness and hopelessness. A bleak outlook—nothing will ever get better and there's nothing you can do to improve the situation.
  • Loss of interest in daily activities. No interest in or ability to enjoy former hobbies, pastimes, social activities.
  • Appetite or weight changes. Significant weight loss or weight gain—a change of more than 5% of body weight in a month.
  • Sleep changes. Either insomnia, especially waking in the early hours of the morning, or oversleeping.
  • Psychomotor agitation or retardation. Either feeling “keyed up” and restless or sluggish and physically slowed down.
  • Loss of energy. Feeling fatigued and physically drained. Even small tasks are exhausting or take longer.
  • Self-loathing. Strong feelings of worthlessness or guilt. Harsh criticism of perceived faults and mistakes.
  • Concentration problems. Trouble focusing, making decisions, or remembering things.

Depression can often look like dementia; many of the symptoms are the same. However, depression can be reversible with proper treatment. Depression often accompanies dementia.


Anxiety Disorder
In addition to the primary symptoms of irrational and excessive fear and worry, other common emotional symptoms of anxiety include:


  • Feelings of apprehension or dread
  • Trouble concentrating
  • Feeling tense and jumpy
  • Anticipating the worst
  • Irritability
  • Restlessness
  • Watching for signs of danger
  • Feeling like your mind's gone blank


Anxiety is more than just a feeling. As a product of the body's fight-or-flight response, anxiety involves a wide range of physical symptoms. Common physical symptoms of anxiety include:


  • Pounding heart
  • Sweating
  • Stomach upset or dizziness
  • Frequent urination or diarrhea
  • Shortness of breath
  • Tremors and twitches
  • Muscle tension
  • Headaches
  • Fatigue
  • Insomnia


The link between anxiety and depression
Many people with anxiety disorders also suffer from depression at some point. Anxiety and depression are believed to stem from the same biological vulnerability, which may explain why they so often go hand in hand. Since depression makes anxiety worse (and vice versa), it's important to seek treatment for both conditions.


Anxiety disorders share some of the same symptoms of Alzheimer's; however it is a treatable disease.

Schizophrenia is a chronic illness. Medications assist in reducing the symptoms but do not reverse the disease process. 


You may have patients in your work environment who have a history of schizophrenia. It is extremely important to know the person's functional and medical history.

The symptoms of schizophrenia fall into three broad categories:

  • Positive symptoms are unusual thoughts or perceptions, including hallucinations, delusions, thought disorder, and disorders of movement.
  • Negative symptoms represent a loss or a decrease in the ability to initiate plans, speak, express emotion, or find pleasure in everyday life. These symptoms are harder to recognize as part of the disorder and can be mistaken for laziness or depression.
  • Cognitive symptoms (or cognitive deficits) are problems with attention, memory, and the executive functions that allow us to plan and organize.

How does this impact your therapy goals and treatment?


You may have determined the person's Allen Cognitive Level, and are providing the appropriate environmental adaptations, task simplification, and cueing, but you're not facilitating best performance.

When we attempt our nonpharmacological approaches, with the understanding that these symptoms may be related to the person's decreased ability to initiate, concentrate, attend, sequence, etc., and we do not see any changes, perhaps this is a psychiatric illness (remember we must discover a pattern of behavior, not just one observation).


When the psychiatric symptoms seem to be impeding performance, how might that impact the patient's:

  • Well-being?
  • Ability to perform at best ability?
  • Ability to benefit from therapy?
  • Safety?
  • Discharge plan?


What to do about it

  • Complete a cognitive assessment using the Allen Model, including using knowledge of the person's past medical history, Can do, Will do, and May do.
  • Interface with nursing to:
    • Determine possible causes of the behavior and the pattern of behavior.
    • Attempt non-pharmacological approaches consistently with the team.
    • Review these approaches with the team to determine what has been successful.
    • Include these approaches in your treatment plan.
    • Recommend initiation of appropriate medications if non-pharmacological interventions are not successful.
  • Monitor the patient for the psychiatric symptoms.
  • Report change in symptoms to nursing staff to assist in determining effectiveness of  non-pharmacological approaches or medication.
  • Continue to discover the person's abilities and facilitate those abilities through environmental adaptation and appropriate caregiver approach.

Case Scenario
A woman comes into the long-term care facility after a hospitalization due to exacerbation of CHF. She was diagnosed with Alzheimer's disease three years ago. She had been living with her husband, who was providing care as needed. She had been performing her basic ADL tasks with intermittent cues for picking out the appropriate clothing for the occasion, using the appropriate amount of perfume and make-up, and changing her clothing regularly. Her husband was completing all IADLs. She was ambulating independently, but was at risk for falls when fatigued. She required consistent cuing to take her nebulizer treatment 2x a day.


On the unit, she paces up and down the halls. Frequently, she is up throughout the night. She stops in patient rooms and offices asking, “Where should I go?” She becomes easily upset, yelling when she is unable to find someone to help her. She will walk until exhausted if not assisted by staff to take a break and focus on an activity. She has difficulty attending to the instructions from the therapist and quickly gets up to leave when she is not provided with constant one-to-one attention.


What psychiatric symptoms is she exhibiting?
Answer: Anxiousness, trouble concentrating or attending, irritability, restlessness, insomnia.


How do we determine if these are symptoms of ADRD or a psychiatric illness?
Answer: Complete the initial cognitive assessment. Provide appropriate approach and environmental adaptations matched to the determined cognitive level of the patient. Tap into the person, her interests and values, address her emotional needs, provide reassurance, and always answer questions supportively (even if she repeats questions frequently). Provide structured opportunities to expend energy through walking, exercising, assisting with tasks on the unit, and purposeful activity.


Interface with nursing staff to provide consistent approaches. Observe to see if the approaches are successful and if they decrease or eliminate the psychiatric symptoms. Continue to assess the person for improvement in cognition and function through skilled observation and/or the use of a battery tool. 


If non-pharmacological approaches are not successful and medications are initiated, continue to assess the person for improvement in cognition and function and report to nursing staff to assist in determining the effects of the medication.  


What would be your treatment plan?
Answer: When you have discovered the person's BATF, with a reduction in psychiatric symptoms, provide the just-right challenge. Train caregivers in the amount and type of assistance she needs based on her current cognitive level. Encourage further psychiatric intervention and support. Interface with nursing to train the caregiver(s) in signs and symptoms of the psychiatric illness.