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Related Subjects: |Dementias |Abbreviated Mental Test Score (AMTS) |Alzheimer disease |Dementia with Lewy bodies |Frontotemporal dementia |Corticobasal degeneration |Creutzfeldt Jakob disease |Vascular Dementia |Anti Dementia Drugs |AIDS Dementia Complex |Normal Pressure Hydrocephalus |Acetylcholinesterase inhibitors |Mental Capacity Act 2005 |Behavioural and Psychological Symptoms of Dementia

Introduction

• Behavioural and Psychological Symptoms of Dementia develop in more than 90% of individuals diagnosed with dementia.
• Symptoms may include delusions, hallucinations, aggression, screaming, restlessness, wandering, depression, and anxiety.
• Other symptoms include disinhibition, sexual behaviours, apathy, sleep disturbances, and compulsive or repetitive behaviours.
• BPSD results in impaired quality of life, increased cost of care, rapid cognitive decline, and massive caregiver burden.

Prevalence

• BPSD extremely common in the community (60%), and in nursing homes (80%).
• More than 90% of patients with dementia develop BPSD over 5 years

Differential causes that mimic BPSD

• Acute Hypo/Hyperactive Delirium, Severe Depression
• Pain: look for verbal/non verbal causes. Limb avoidance. Examine top to toe. Check for dental pain. Musculoskeletal. Catheter.
• UTI/Chest infection/Constipation/ Hyponatraemia
• Environmental : overstimulating. Staff issues not trained to manage dementia
• Medications: anticholinergics, medications known to increase the risk of delirium e.g. opioids, benzodiazepines, antipsychotics, anticonvulsants, antihistamines, antihypertensives (especially if hypotension), corticosteroids, tricyclics, digoxin, antiparkinsonian medication

What is BPSD:

• Behavioural and Psychological Symptoms of Dementia (BPSD) refers to a group of symptoms of disturbed perception, thought content, mood or behaviour, frequently occurring in patients with dementia.
• Challenging non-cognitive symptoms — including hallucinations, delusions, anxiety, and marked agitation.
• Challenging behaviour — includes aggression, agitation, wandering, hoarding, sexual disinhibition, apathy, and disruptive vocal activity (such as shouting).
• Challenging behaviour is often an active attempt by the person with dementia to meet or express a physical or psychological need. For example, agitation may be communicating boredom, anxiety, embarrassment or be a response to pain or discomfort or an environmental challenge, e.g. noise.

Management

• Exclude a new delirium. May require MSU and screening bloods (U&Es, FBC, CRP, B12, Folate, TFTs) as a minimum and management if short history, <2 weeks, of confusion, hallucinations, and /or delusions with fluctuating cognition). Review all medications (including anticholinergics, medications known to increase the risk of delirium e.g. opioids, benzodiazepines, antipsychotics, anticonvulsants, antihistamines, antihypertensives (especially if hypotension), corticosteroids, tricyclics, digoxin, antiparkinsonian medication). Treat and reassess.
• It is recommended that non-pharmacological approaches (therapy that does not involve medication) are used as a first-line approach. A well-lit ward area that is quiet with trained staff is the minimum. An assessment and care-planning approach, which includes behavioural management, should be followed as soon as possible.
• If the distress and or agitation are less severe, non-pharmacological interventions should be used before a pharmacological intervention is considered.
• It is important to have Person-centred care. Look at reducing noise and overstimulation. Ensure easy access to toilets/toileting. Ensuring well-lit surroundings. Improving time and day orientation (e.g. visible calendar/clock). Windows and normal lighting. Homelike environment and reassuring as possible. Separating non-cognitively impaired residents from people with dementia. Constantly trained staff caring for patients
• If severe behavioural problems are present, consider haloperidol in small doses (0.5-4 mg) short term only. For rapid tranquillisation, give IM haloperidol or lorazepam. Avoid IV usage.
• If depression symptoms are present consider selective serotonin reuptake inhibitors such as Citalopram 10-20 mg, Sertraline 50-100 mg or Mirtazapine 15-45 mg.
• Consider a therapeutic trial of regular paracetamol for at least one week, even if no obvious evidence of pain, since untreated pain could be an underlying cause of agitation/restlessness. If there is a positive response treatment with Paracetamol should continue
• Target symptoms should be identified, quantified and documented. Target symptoms may include apathy, psychosis, aggression, moderate agitation/anxiety, severe agitation/anxiety, poor sleep. These need ongoing assessment and a diary kept.
• If an antipsychotic is deemed necessary the choice of antipsychotic should be made after an individual risk versus benefit analysis. If there is dementia the antipsychotic of choice is risperidone, which is licensed for BPSD at a dose of up to 1mg twice daily for up to 6 weeks. It must be used with extreme caution as all antipsychotics have been shown to increase the risk of stroke. Should the patient require antipsychotic medication and a trial of risperidone has proved unsuccessful, olanzapine and aripiprazole are suitable alternatives. Olanzapine and aripiprazole is not licensed for this indication
• Regular review is needed and treatment beyond 6 weeks should not occur without a full, documented review of ongoing clinical need. The dose should start low and then be slowly titrated.
• If the drug is continued there must be ongoing assessment every 3 months or according to clinical need. Trial discontinuation may be considered.

References

• Guidelines for the Management of Behavioural and Psychological Symptoms of Dementia (BPSD) in Primary and Secondary Care