As the disease progresses, more amyloid plaque builds up on the neurons causing increased atrophy of the cerebral cortex. Additionally, the decrease in the production of the neurotransmitters necessary to transmit the messages of mood and memory continues. Behavioral problems begin to manifest during this phase as well as the loss of both gross motor and fine motor movement. Day to day functional loss becomes noticeable and it is during this phase where toileting, dressing and walking issues develop. During the Middle Stage more neurons become tangled and die making it increasingly more difficult for any messages to be transmitted and received.
The hallmark of the Middle-Stage of the disease is therefore marked functional loss in the individual. Increasing memory loss causes problems with the sequencing of ADLs along with perceptual-motor problems exhibited with the decline of both gross motor and fine motor skills. With the decrease of available neurotransmitters such as dopamine, serotonin, and acetylcholine in the brain, behavior problems (often called “positive symptoms”) begin to appear such as wandering, agitation, vocal outbursts, and sleep disturbances which require more intensive supervision and care. Delusions (often paranoid) and hallucinations may also occur.
The medications that are available to treat these disorders, antidepressants, antipsychotics, and sedatives all have side effects and can interact with other medications. Thus non-drug interventions should be attempted before resorting to medications. If the decision is made to treat a difficult behavior with medication, some physicians may order what is known as a “typical” neuroleptic, such as Haldol, though the atypical antipsychotics which include risperidone (Risperidol), quetiapine (Seroquel), olanzepine (Zyprexa), aripiprazole may be better tolerated than the more traditional agents. They also tend to have fewer side effects which can cause a cumulative effect in the individual over time.
The decision to use an antipsychotic medication generally occurs when all other treatment options fail. Choosing to use these medications generally occurs when the emotional distress a person with dementia is experiencing interferes with their quality of life.
Since functional losses and behavioral issues occur in the Middle Stage of the disease, this is the most common time when families begin to seek medical intervention or assistance with their family member. At this stage the person may become incontinent and their sleep cycle may be disturbed (up at night, sleeping during the day). Personality and emotional changes become more pronounced and the caregiver simply becomes overwhelmed.