Sir: Clinicians are often reluctant to use psychomotor stimulants in patients with disinhibition from frontal lobe dysfunction because of the concern that these medications will worsen behaviors or result in psychosis. 1 We contrasted the effects of dex-troamphetamine and quetiapine, an atypical antipsychotic often used to treat agitation in dementia patients with cognitive and behavioral symptoms, in 8 patients with behavioral-variant frontotemporal dementia (FTD) in a double-blind crossover trial. We were interested in testing a stimulant for several reasons: (1) there is autopsy, cerebrospinal fluid, and imaging evidence of dopaminergic deficiencies in FTD (reviewed in Huey et al. 2); (2) there is a clinical association between FTD and basal ganglia dopaminergic dysfunction (i.e., parkinsonism) 3 ; and (3) executive dysfunction associated with psychiatric illness (e.g., attention-deficit/hyperactivity disorder) can improve with do-pamine augmentation. 4 Method. All 8 patients had behavioral symptoms. Over 1 week, medication daily dosage was gradually increased to either 20 mg of dextroamphetamine or 150 mg of quetiapine in divided doses. The patients returned home on the target dose for 3 weeks before returning to our clinic for reevaluation. At this point, the patients were tapered to half the study medication for 2 days before discontinuation and then underwent washout for 1 week, and the process was then repeated with the other medication. Medication order was randomized, and the patients, care-givers, and clinicians were blinded to the order. The individuals assigned durable power of attorney by the patients provided written consent, and all patients gave assent. The study was approved by an institutional review board and was conducted from November 2004 to August 2006. The primary measure of behavioral symptoms was the Neuropsychiat-ric Inventory (NPI), 5 and the primary cognitive measure was the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). 6 Results. All patients were able to tolerate the full dose of dextroamphetamine. One patient experienced sedation on que-tiapine treatment and was unable to tolerate the full dose. The most common adverse effect of both medications was sleep disturbance. The results for the total NPI can be seen in Figure 1. Using nonparametric methods (a 2-tailed Friedman test), there was a significant effect of treatment on the total NPI (p = .05). Post hoc Wilcoxon signed-rank tests showed that the total NPI was significantly lower than pretreatment baseline on dextro-amphetamine (p = .02), but there was no significant difference between baseline and quetiapine, nor between quetiapine and dextroamphetamine. The NPI subscales that decreased the most on dextroamphetamine were apathy (2.8 points) and disinhibi-tion (2.4 points). There was no significant overall effect of treatment on the RBANS. The order of magnitude of this effect is large compared to that observed in pharmacologic trials for behavioral symptoms of Alzheimer's disease. A summary of ava...

These preliminary findings suggest that the EXIT is a valid and reliable instrument for the assessment of executive impairment at the bedside. It correlates well with level of care and problem behavior. It discriminates residents at earlier stages of cognitive impairment than the MMSE.

The authors compared the efficacy and side effects of trazodone and haloperidol for treating agitated behaviors associated with dementia. Twenty-eight elderly patients with dementia and agitated behaviors were randomly assigned to double-blind treatment with either trazodone (50-250 mg/day) or haloperidol (1-5 mg/day) for 9 weeks. There was no significant difference in improvement between the medication groups. Adverse effects, however, were more common in the group treated with haloperidol. Improvement in individual areas suggested that repetitive, verbally aggressive, and oppositional behaviors responded preferentially to trazodone, whereas symptoms of excessive motor activity and unwarranted accusations responded preferentially to haloperidol. These results indicate that moderate doses of trazodone and haloperidol are equally effective for treatment of overall agitated behaviors in patients with dementia, but specific symptoms may respond preferentially to a particular agent.

Mild depressive symptoms in patients with dementia and agitated behavior are associated with greater behavioral improvement by trazodone-treated patients. In contrast, the presence of delusions in concert with behavioral disturbance does not necessarily predict greater behavioral improvement with haloperidol treatment than in subjects without signs of psychosis.

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