Behavioral and Psychological Symptoms of dementia (BPSD) Chris Collins - Old Age Psychiatrist, Christchurch chris.collins@cdhb.health.nz Approaching BPSD: the right mindset Assessment Non-drug management Pharmacotherapy Conflicts of interest to declare : none
BPSD Symptoms of disturbed perception, thought content, mood or behaviour that frequently occur in patients with dementia (International Consensus Conference on Behavioural Disturbances of Dementia, 1996) For more information: http://www.health.gov.bc.ca/library/publications/year/2012/bpsdguideline.pdf
BPSD - how common is it? BPSD is virtually universal among dementia patients, at some stage in their illness Affective symptoms are more common in earlier stages Agitation & psychosis are more common in later stages BPSD contibutes greatly to carer burden, and often leads to residential placement
The person-centred approach BPSD can be: communicating an unmet need a symptom of a wider problem Empathy, patience, tolerance & understanding are key Terminology is important BPSD is a product of the illness; not helpful to view as bad
Psychiatric symptoms - 1 Delusions (~30%) - theft, infidelity, persecution, abandonment, phantom boarder Misidentification (~30%) - own home, relatives, TV, mirror image Hallucinations (~25%) - especially visual
Psychiatric symptoms - 2 Depression (~20-40%) - often atypical, easily missed - pseudodementia Anxiety states (up to 40%) - situational or pervasive, - catastrophic reactions, panic, compulsions - new onset strongly implies depression
Behavioural symptoms -1 Verbal behaviour constant requests for attention or succour verbal negativism Repetitious phrases or questions repeated yelling disinhibited/tactless remarks
Behavioural symptoms -2 Physical behaviours general restlessness, agitation, sundowning pacing, trailing or intrusiveness inappropriate dressing/undressing trying to get to a different place ( wandering ) handling/hoarding things inappropriately sleep disruption disinhibition/poor impulse control
Behavioural symptoms - 3 Aggressive behaviour Swearing or cursing Verbal threats Resistiveness to cares Punching, slapping, biting, kicking
Behavioural symptoms - 4 Negative symptoms Apathy, inactivity, Daytime drowsiness Social withdrawal Loss of conversational ability
Incidence influenced by Neurobiologic factors (neurochemical, neuropathological) Psychological factors (premorbid personality, response to stress) Environmental factors (physical, social)
Medical Common triggering or exacerbating factors Occult illness, delirium, pain, urinary/fecal retention, visual/hearing problems, drugs/alcohol, medication toxicity Psychological Depression, psychosis, panic, grief, frustration, reactivation of old memories, boredom, difficulty communicating Physiological Cold, wet, hunger, thirst, noise, tiredness, discomfort Environmental Lack of orienting cues, lack of space, restraint, upset by other residents or style of caregiving, disruption of familiar routines, cultural or religious insensitivity Procedures Dressing, toileting, bathing, turning, catheterisation, cleaning teeth, etc
Helping BPSD Clarify and quantify the problem(s) Does it really matter? Involve carers Attempt to understand the problem(s) : specific cognitive deficits underpinning medical &/or psychiatric factors environmental & psychosocial factors unmet human needs Non-pharmacological management Drug treatment
Aids to assessment Behaviour charts : A= Antecedent B= Behaviour C= Consequences (Rating scales)
Non-pharmacological measures Simple, pragmatic remedies can sometimes be strikingly effective (eg attention to basic physiologic needs) Reassurance, Re-orientation, Re-direction Effective communication (simple, repeated, clear, unhurried; choices not orders; avoid arguing or scolding; eye contact, touch; use humour and affirmation;) Adjust physical/social environment (try to be flexible and creative)
Specific activities or therapies Reminiscence Validation therapy Behaviour modification Cued recall Music therapy and dance Motivational therapy Doll therapy Pet therapy
Principles of pharmacological treatment Only when BPSD is causing moderate or severe distress Not all target symptoms are appropriate for drug treatment Sedation for emergencies only Choice of drug determined by the predominant psychiatric syndrome pertaining (psychosis, depression, anxiety) Onset of therapeutic benefit usually delayed
Pharmacotherapy Reviews indicate modest benefits and large placebo responses Antipsychotics Antidepressants Cholinesterase inhibitors (Benzodiazepines)
Antipsychotics Potentially useful for: hallucinations, paranoid delusions; aggression (sometimes) Useless for: wandering, urination problems, calling out (unless driven by psychosis), social withdrawal, apathy, intruding into others personal space
Antipsychotics risperidone 0.25-1.0mg bd haloperidol 0.25-2mg bd quetiapine 12.5-100mg per day aripiprazole 10mg per day olanzapine 2.5-10mg per day (clozapine 12.5-50mg per day)
Antipsychotics adverse effects Increased risk of stroke and death Parkinsonism Falls Sedation Dulling, less able to participate Tardive dyskinesia Constipation
Antipsychotics good prescribing Start low, go slow; increase not more often than weekly Time dose according to behaviour occurrence Monitor for side effects REVIEW regularly; if it doesn t help, STOP! If it does help, review at least 3 monthly Attempt to taper it off beware the eternal prescription
Antidepressants citalopram / escitalopram sertraline mirtazapine moclobemide Potentially helpful for: dysphoria, anxiety, agitation, sleep More likely to try this if PH depression
Cholinesterase inhibitors donepezil rivastigmine (unsubsidised) Potentially useful for : apathy, hallucinations, agitation