Behavioural and Psychological Symptoms of Dementia (BPSD) in Primary Care

Behavioural and Psychological Symptoms of Dementia (BPSD) in Primary Care Dr. John Puxty Ontario s Ontario s Strategy Strategy for Alzheimer for Disease and Related Dementia: Initiative #2, #2, Physician Physician Education Education

Behavioural and Psychological Symptoms of Dementia (BPSD) Behaviour is responsive. It occurs in response to stimuli in the physical, social, or emotional environments. Variety of changes occurring in dementia that can alter a behavioural response to an external event or interaction. These include changes: in an individual s perception and interpretation of external stimuli, capacity for attention and filtering, and degree to which emotional and instinctive responses are moderated The resulting changes in behaviour and mood are often referred to as Behavioural and Psychological Symptoms of Dementia (BPSD).

Categories of Major Behavioural and Psychological Disturbances in Dementia Depression Psychosis Agitation non-aggressive physical (wandering) verbal (screaming) aggressive physical (hitting) verbal (cursing) Resistance to care Disinhibition Diurnal rhythm disturbances Sleep disorders Sexually inappropriate behaviour

Frequency of Behavioural and Psychological Problems in Dementia Any symptom can occur during any stage in dementia, and virtually all patients demonstrate some type of BPSD (Reisberg et al., 1989). One study of BPSD found that 64% of patients with Alzheimer s Disease (AD) had one or more BPSD at initial evaluation (Devanand, et al., 1997). The majority of these people were living at home. Another study of just community living elderly with dementia reported at least 61% had an example of BPSD and a third of the symptoms were moderate to severe (Lyketso et al 2000).

Common Behavioural Changes throughout the Course of Alzheimer s Disease

BPSD in Dementia other than Alzheimer s Disease (Vascular Dementia) Some studies have found noted differences between the prevalence and type of BPSD in Alzheimer s Disease (AD) and Vascular Dementia (VaD) (Cohen et al., 1993; Tariot and Blazina, 1994), for example a higher rate of delusions in AD and a higher rate of depression in VaD (Lyketsos et al., 2000).

BPSD in Dementia other than Alzheimer s Disease (Frontotemporal Dementia) Frontotemporal dementia is typically associated with a higher incidence of BPSD early in the course of the illness. The reason for initial consultation is more likely to be related to behavioural difficulties than memory loss. These include disinhibition (socially tactless), impulsivity, compulsive behaviours (including over-eating), grabbing, hypersexuality, and verbal outbursts. The anatomic distribution of asymmetric atrophy in frontotemporal dementia has been correlated with specific behavioural manifestations.

BPSD in Dementia other than Alzheimer s Disease (Lewy Body Dementia) Lewy Body Dementia is characterized by the early appearance of visual hallucinations, relatively mild abnormalities of cognition and features of extrapyramidal impairment. The visual hallucination are often characterized by being structured and often non-distressing to the individual. Attempts to treat these with anti-psychotics may be associated with marked extrapyramidal side-effects Over half may present with an acute fluctuations of cognition resembling delirium. After resolution of which they often have findings of impaired attention, executive, visuospatial function, & constructional abilities with relatively intact memory.

Impact of BPSD on Caregivers Caregiver burden and stress present a major issue in moderate to severe dementia both in community and long-term care setting Certain behavioral problems are more likely to precipitate a request for admission to LTC, including: physical and verbal aggression night-time behavioural issues paranoia/hallucinations depressive symptoms wandering (Hope T et al. Int J Geriatr Psychiatr 1998;13(10):682-90., Gilley DW et al. Psychol Med 2004;34(6):1129-35.)

Understanding Brain and Behaviour A Structural / Functional Approach Understanding the normal functions of the brain and their impact on function and behaviour provides an insight as to why the person with dementia (with damage to certain parts of the brain) might react, interpret and act differently. Their reality is not our reality.

Case: The Imposter A 74-year old woman has a 5-year history of mild memory problems. She has had occurrences where she does not recognize her friends, or she has become lost. Her family has become distressed by these new behaviours. She has recently started to accuse her husband of being an imposter; saying that this old man is not her husband. She has become increasingly agitated and has wandered from her home, necessitating her return by police. She calls her daughter at night and asks to be taken home. She has started locking her bedroom door.

Summary of Brain Function and Behaviour Brain area Function Deficient Behaviour Frontal lobes Executive function Social inhibition Language Temporal lobes Language Memory Parietal lobes Language analysis, Calculations, Spatial perception, Sequencing Occipital lobes Vision Depth perception Cerebellum Brain stem Sub-cortical areas Limbic Hippocampus Balance Voluntary & Involuntary movements Memory retrieval Connects behaviour with memories Regulates sleep, appetite

Summary of Brain Function and Behaviour Brain area Function Deficient Behaviour Frontal lobes Temporal lobes Executive function Social inhibition Language Language Memory Problems with planning, initiating, executing in a planned, organized manner Re-emergence primitive reflexes Motor Aphasia Aphasia Amnesia Unable to initiate (may appear lazy, uncooperative with requests) Impulsivity, may be disinhibited Can t plan holiday, activities of the day, dinner party, etc Grabbing (Grasp reflex) and Paratonia. Frustration with aphasia, annoying repetitions, unsafe use of tools, stove, disorientation. Parietal lobes Language analysis, Calculations, Spatial perception, Sequencing Difficulty understanding Visual-spatial planning difficulties Difficulty sequencing movements Apraxia Agnosia Anosognosia Vague historian, Unable to manage finances or driving Dressing, gait or eating difficulties may be present Failure recognize people/objects Lacks insight into disease Occipital lobes Vision Depth perception Cerebellum Brain stem Sub-cortical areas Balance Voluntary & Involuntary movements Limbic Hippocampus Memory retrieval Connects behaviour with memories Regulates sleep, appetite

Summary of Brain Function and Behaviour Brain area Function Deficient Behaviour Frontal lobes Temporal lobes Executive function Social inhibition Language Language Memory Problems with planning, initiating, executing in a planned, organized manner Re-emergence primitive reflexes Motor Aphasia Aphasia Amnesia Unable to initiate (may appear lazy, uncooperative with requests) Impulsivity, may be disinhibited Can t plan holiday, activities of the day, dinner party, etc Grabbing (Grasp reflex) and Paratonia. Frustration with aphasia, annoying repetitions, unsafe use of tools, stove, disorientation. Parietal lobes Language analysis, Calculations, Spatial perception, Sequencing Difficulty understanding Visual-spatial planning difficulties Difficulty sequencing movements Apraxia Agnosia Anosognosia Vague historian, Unable to manage finances or driving Dressing, gait or eating difficulties may be present Failure recognize people/objects Lacks insight into disease Occipital lobes Vision Depth perception May not scan or interpret environment properly Startled response Afraid of tub water (appears too deep) Messy when pouring liquids, etc. Cerebellum Brain stem Sub-cortical areas Balance Voluntary & Involuntary movements Limbic Hippocampus Memory retrieval Connects behaviour with memories Regulates sleep, appetite

Summary of Brain Function and Behaviour Brain area Function Deficient Behaviour Frontal lobes Temporal lobes Executive function Social inhibition Language Language Memory Problems with planning, initiating, executing in a planned, organized manner Re-emergence primitive reflexes Motor Aphasia Aphasia Amnesia Unable to initiate (may appear lazy, uncooperative with requests) Impulsivity, may be disinhibited Can t plan holiday, activities of the day, dinner party, etc Grabbing (Grasp reflex) and Paratonia. Frustration with aphasia, annoying repetitions, unsafe use of tools, stove, disorientation. Parietal lobes Language analysis, Calculations, Spatial perception, Sequencing Difficulty understanding Visual-spatial planning difficulties Difficulty sequencing movements Apraxia Agnosia Anosognosia Vague historian, Unable to manage finances or driving Dressing, gait or eating difficulties may be present Failure recognize people/objects Lacks insight into disease Occipital lobes Vision Depth perception May not scan or interpret environment properly Startled response Afraid of tub water (appears too deep) Messy when pouring liquids, etc. Cerebellum Brain stem Sub-cortical areas Balance Voluntary & Involuntary movements Abnormal gait/balance, Slowness of movement Swallowing problem Falls Slow movements Aspiration pneumonia Limbic Hippocampus Memory retrieval Connects behaviour with memories Regulates sleep, appetite

Summary of Brain Function and Behaviour Brain area Function Deficient Behaviour Frontal lobes Temporal lobes Executive function Social inhibition Language Language Memory Problems with planning, initiating, executing in a planned, organized manner Re-emergence primitive reflexes Motor Aphasia Aphasia Amnesia Unable to initiate (may appear lazy, uncooperative with requests) Impulsivity, may be disinhibited Can t plan holiday, activities of the day, dinner party, etc Grabbing (Grasp reflex) and Paratonia. Frustration with aphasia, annoying repetitions, unsafe use of tools, stove, disorientation. Parietal lobes Language analysis, Calculations, Spatial perception, Sequencing Difficulty understanding Visual-spatial planning difficulties Difficulty sequencing movements Apraxia Agnosia Anosognosia Vague historian, Unable to manage finances or driving Dressing, gait or eating difficulties may be present Failure recognize people/objects Lacks insight into disease Occipital lobes Vision Depth perception May not scan or interpret environment properly Startled response Afraid of tub water (appears too deep) Messy when pouring liquids, etc. Cerebellum Brain stem Sub-cortical areas Balance Voluntary & Involuntary movements Abnormal gait/balance Slowness of movement Swallowing problem Falls Slow movements Aspiration pneumonia Limbic Hippocampus Memory retrieval Connects behaviour with memories Regulates sleep, appetite Misinterprets events Emotional lability Blaming others Irritability and depression Day-night reversal Hot/cold perception changes

Case: The Imposter Her new behaviours are likely attributable to a combination of agnosia, anosognosia and amnesia. She does not recognize her husband; nor does she appreciate that they have aged or that she has memory problems. Management should be mainly nonpharmacological. If she is not on ACEI such as Donepezil it should be considered. A trial of an SSRI may be indicated.

Physician s Approach to Collaborative Care Planning in BPSD: 5 Questions 1. What has changed and what are the main concerns of caregivers? 2. What are the consequences or risks of the behaviours or psychological symptoms, if allowed to continue? 3. What are possible contributory factors to the behaviours or psychological symptoms (think P.I.E.C.E.S.)? 4. What needs to be done? 5. How should things be monitored and re-evaluated?

Case: Applying the 5 Questions John is a 72-yr old man with a 3-year history of AD who has recently started to sleep on the couch downstairs while watching TV His wife hears him scream one night that there is an intruder in the house, and hears him leave She finds him some time later wandering the neighborhood with a stick and threatening passersby The next day John s distressed wife and daughter bring him to your office. You find him to be similar to previous visits and cooperative.

Case: Understand (Q1) Q1. What are the main concerns and what has changed? The main concerns of the family are the risk for wandering outside the house and potential return of sudden and uncharacteristic threatening behaviour. On reviewing his cognitive deficits you note that he has problems with short-term memory, difficulty in verbal fluency (naming 10 animals), spatial orientation (clock and pentagon completion), and abstraction. His family reports that he has been withdrawing from previous hobbies (gardening and cards), and is less attentive of self-grooming. On occasions he has become lost in normally familiar situations. He appears to have a mild to moderate stage of AD with multiple deficits noted. This is the first time a disruptive behaviour of this type has been seen, and therefore represents the most important change.

Case: Understand (Q2) Q2. What are the consequences and risks of the behaviours or psychological symptoms if allowed to continue? If one cannot identify the causes of this new behaviour, it may occur again and put John at risk of wandering outside the home, inappropriately dressed for the weather. It may also cause fear in the neighborhood. In the immediate situation there is also a danger that a single incident may result in John being labeled as aggressive and threatening, which may negatively influence care providers.

Case: Understand (Q3) Q3. What are likely contributory factors to the behaviours or psychological symptoms (think P.I.E.C.E.S.)? His behaviour likely arises from his perception that an intruder has actually entered his home. The impaired perception may be caused by a combination of agnosia (people on TV are actually inside the house) and grogginess on first awaking. Believing intruders were threatening his family, John attempted to chase them away. Subsequently he became lost and fearful, hence his threatening behaviour.

Case: Action (Q4) Q4. What needs to be done? Screen for sensory miscues (hearing or vision) that could potentially contribute to John s perceptual problems Review medication use, especially alcohol and across the counter medication, for potential anticholinergic or somnolence effects Exclude any new medical issues (e.g. Urinary Tract Infection) that may be causing a delirium Management ideally should be non-pharmacological to minimize the risk of recurrence of the behaviour. This might include: reducing any sensory miscues (e.g. lighting, review vision and hearing), improving sleep habit/hygiene - use of a snooze timer education of family in contributory factors and supportive care strategies

Case: Follow-Up (Q5) 5. How should things be monitored and re-evaluated? The event is situational and hopefully will respond to measures as previously discussed, however, it would be important to review and discuss the potential for similar responsive behaviours in the future

Approach to Assessing and Managing BPSD What has changed? What are the risks and consequences? What are the contributory factors? What should be done? How should things be monitored? Pharmacological Non-pharmacological

Behaviours that will not respond to medications Simple wandering Inappropriate urination / defecation Inappropriate dressing / undressing Repetitive activities (perseveration) or vocalizations Hiding / hoarding Eating inedibles Tugging at / removal of restraints Pushing wheelchair bound co-patients

BPSD that may get worse with medications BPSD: aggressive / disinhibited visual hallucinations / confusion motor restlessness apathetic / withdrawn May get worse with: benzodiazepines & alcohol drugs with anti-cholinergic properties anti-psychotics (akathisia) benzodiazepines or antipsychotics

Non-pharmacological management of BPSD Derived from an understanding of the contributing factors to the behaviours Strategies that reduce and/or contain the behaviours Reinforcement of retained skills/abilities Crucial features: Timing Priming Miming The only safe and efficacious treatment for those problems that will not respond to medication

Non-pharmacological management of BPSD Non-Pharmacological Strategies Approach Schedule Communication Minimize failure without dependency Appropriate activity/environment Attention to personal care Preventative care (bowels/bladder/sleep) Hydration / nutrition Medication use

Consider pharmacological treatment of BPSD when: Behaviour is: dangerous to self or others distressing to self or others damaging to social relationships persistent AND has not responded to comprehensive non-pharmacological treatment plan, including the removal of possibly offending drugs OR The individual requires emergency treatment to allow proper investigation of underlying health issues

Behaviours that may respond to medications Physical aggression Verbal aggression Anxiety and restlessness Sadness, crying, anorexia, insomnia and other symptoms indicative of depression Withdrawal and apathy Sleep disturbance Wandering with agitation / aggression Elation, pressured speech and hyperactivity (manic-like symptoms) Persistent delusions and hallucinations Sexually inappropriate behaviour with agitation

Pharmacological management of BPSD - Guiding principles: Optimize treatment for underlying health issues Remove medications that are possible precipitants Introduce one drug at a time, and monitor the effect Start low (dose) and go slow (titration) Optimize the dose and duration to allow an adequate trial before switching to another medication Ensure that the chosen medication won t worsen dementia or other health issues Check for potential drug-drug interactions before finalizing the choice of medication

Medications for treating BPSD Target Symptoms Medication Starting Dose (mg/day) Average Target Dose (mg/day) Delusions Atypical Antipsychotics: Hallucination Risperidone 0.25-0.5 0.5-2.0 Aggression Olanzapine 2.5-5 2.5-7.5 Quetiapine 12.5-25 50-400 Sadness Antidepressants: Irritability Citalopram 10 10-40 Anxiety Sertraline 25 50-100 Insomnia Venlafaxine 37.5 37.5-150 Mirtazapine 15 15-45 Trazodone 12.5-25 50-100

Medications for treating BPSD Target Symptoms Medication Starting Dose (mg/day) Average Target Dose (mg/day) Mood swings Euphoria Impulsivity Mood stabilizers: Valproic Acid 250 500-1000 Agitation Apathy Cholinesterase Inhibitors Memantine As directed 5 mg daily As directed 10 mg BID Irritability Anxiety (short term use in predictable situations) Anxiolytics: Lorazepam Oxazepam 0.25-0.5 5-10 0.5-1.5 10-30

Treatment of severe agitation likely due to delirium Low dose Haloperidol: consider for emergency, short-term use (days) while addressing cause(s) of delirium Consider atypicals: Quetiapine, Risperidone Consider Loxapine or Perphenazine: Assess 3 C s: Cholinergic Cardiovascular Constriction (EPS)

Treatment of behavioural problems due to Lewy Body Dementia (LBD) Cholinesterase inhibitors: now first line of treatment need to try over several weeks Trazodone: if cholinesterase inhibitors ineffective or too early in treatment watch BP Antipsychotics should generally be avoided in residents with LBD: potential for severe adverse effects If an antipsychotic is absolutely necessary in LBD or Parkinson s: Quetiapine may be less likely than other atypicals to exacerbate the motor symptoms (Friedman & Factor, 2000)

Sleep disruption may exacerbate BPSD Possible causes: Physical: pain urination Intellectual Brain Changes: REM Behavioural Disorder seizures Sleep Disorders: Sleep Apnea Restless Leg and Periodic Leg Movement No Sleep = Seriously Effects Daytime Behavior (DOS)

Summary Take Home Messages Health Care Teams have an important role in helping care providers understand, how the changes in the brain that occur in dementia affect a person s behaviour. They can help to guide caregiver interactions with the individual, and identify supportive care strategies that enable the individual s functional abilities/potential rather than confront their cognitive losses. In this way, challenges related to the behavioural changes that occur in cognitive impairment will be minimized for the individual and others. www.sagelink.ca is a resource for both informational and clinical resources on Dementia and BPSD