Behavioural and Psychological Symptoms of Dementia (BPSD)

Behavioural and Psychological Symptoms of Dementia (BPSD) will develop in more than 90% of individuals diagnosed with dementia.^[1] Symptoms 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.

BPSD is extremely common in the community (60%), and in nursing homes (80%). More than 90% of patients with dementia develop BPSD over 5 years, and the majority of cases have serious clinical implications.^[2]

Theoretical models that explain the causes of BPSD include:

1. Unmet Needs Model (i.e. - the patient is unable to express needs)
2. Progressively Lowered Stress Threshold Model (i.e. - ability to deal with stress or stimuli is impaired)
3. ABC Model (Antecedent-Behaviour-Consequence learning theory)

A broad differential diagnosis must be considered at all times:

Managing BPSD requires a thorough assessment, involving multiple sources of information, including a medical history, social history, personal history, and habits. Family and caregivers also need to be interviewed. There also needs to be an adequate physical exam, bloodwork, and urine cultures.

It can often be helpful to break down the BPSD into ABC (Antecedent, Behaviour, and Consequences) charting. This helps you identify if there are patterns to the behaviours, and allows the use of behavioural techniques to extinguish some behaviours, instead of medications. The key is to avoid positively reinforcing unwanted behaviours (e.g. - man screams and nurse soothes him, which leads to more screaming to seek soothing in the future) and encourage the reinforcement of alternate behaviours (e.g. - screaming man gets only attention when he is calm). The challenge with implementing these behavioural care plans is that all staff and caregivers have to be involved and follow the plan. Otherwise, intermittent reinforcement increases and worsens the behaviour.

In this example, the antecedent is the patient is in situations where she frequently calls out for help and staff are not present. In order to extinguish this behaviour, she should be given more attention when she is calm, to reinforce the alternate behaviour.

The DICE Approach (Describe, Investigate, Create, Evaluate) is a model used to evaluate, manage, and treat BPSD, and to minimize the reflexive use of medications such as antipsychotics.^[9][10] The evidence for non-pharmacological approaches to BPSD is better than the evidence for antipsychotics, and exceedingly better than for other classes of medication.

Non-pharmacological interventions are a cornerstone of managing BPSD, and must not be forgotten! This includes physical exercises and activity programs, music therapy, therapeutic touch, bright light therapy, and aromatherapy.^[11] The challenges with interpreting the efficacy of non-pharmacological interventions is they are often small in sample size, have no control groups, and have inadequate randomization. Other times, the interventions may be effective, but not financially feasible. The bottom line is that non-pharmacological treatments work, but there is no “one-size fits all” solution.

It is important that not all symptoms of BPSD respond to medications, and a comprehensive non-pharmacological approach must be taken!

Citalopram (best evidence), escitalopram, sertraline, and trazadone have comparable effects as antipsychotics, in reducing delusions, anxiety, and irritability/lability.^[12] In the elderly, it is particularly important to monitor for hyponatremia, and sodium levels should be drawn within 4 weeks. Trazodone has inconclusive evidence,^[13] though it is commonly used due to its sedating effects. There are some positive results in the use of trazodone for frontotemporal dementia.^[14]

Antipsychotics are indicated only when there is a significant risk of harm to the patient or others or when the agitation or aggressive symptoms are persistent, recurrent, or severe enough to cause significant suffering and distress, or significant interference with provision of care.^[15] There are clear risks for increased all-cause mortality and stroke risk when antipsychotics are used, and the benefits must outweigh the risks.^[16] There is a 2-3 times increase in relative risk of cerebrovascular adverse event, and 1.7 times increase in risk of death. Although these are only relative risk increases (i.e. - the absolute risk of death is in fact quite low), it is important to obtain consent to treatment. The risk of death is highest for haloperidol, and lowest for quetiapine.^[17] Antipsychotics also can bring on other side effects, including falls, metabolic side effects, hypotension, cognitive impairment, and pneumonia.

Risperidone (only one that has Health Canada approval), olanzapine and aripiprazole have the most evidence for severe agitation, aggression and psychosis associated with BPSD, where there is risk of harm to the patient and/or others. Quetiapine has conflicting evidence, as recent meta-analyses have found a strong placebo effect.^[18] It can be tried in patients with parkinsonism (LBD or Parkinson's Disease (PD)).

There is currently insufficient evidence to recommend for or against the use of acetylcholinesterase inhbitors and/or memantine for the treatment of BPSD in Alzheimer's disease as a primary indication.^[23] Many patients may already been on these medications as part of their disease treatment. There is, however, good first line evidence for the use of donepezil and rivastigmine in behavioural symptoms (especially hallucinations and agitation) related to Lewy Body Dementia (LBD).^[24] It may also be helpful in managing symptoms of depression, anxiety, and apathy.

There is somewhat limited evidence for memantine, and prospective RCTs have been negative.

Carbamazepine been shown to have some utility in treating BPSD.^[25] There is no evidence for valproic acid.

Other potential medications with some positive results include dextromethorphan-quinidine,^[26] and prazosin.^[27]

Always attempt to taper and withdraw pharmacotherapy after 3 months of behavioural stability.

• Bjerre, L. M., Farrell, B., Hogel, M., Graham, L., Lemay, G., McCarthy, L., ... & Welch, V. (2018). Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: Evidence-based clinical practice guideline. Canadian Family Physician, 64(1), 17-27.

• Glass, O. M., Forester, B. P., & Hermida, A. P. (2017). Electroconvulsive therapy (ECT) for treating agitation in dementia (major neurocognitive disorder)–a promising option. International psychogeriatrics, 29(5), 717-726.