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 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.

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]

Agitation, disinhibition, and psychosis from BPSD are associated volume reduction and decreased metabolism in the dorsolateral prefrontal cortex, orbital prefrontal cortex, anterior cingulate, insula, and temporal lobes.^[6] These are areas of the brain responsible for emotional regulation, self-awareness, and perception. Other cluster symptoms such as apathy are more associated with small vessel white matter disease. Importantly, there is no single cause for BPSD, and it is important to go beyond a biological approach. Biopsychosocial and holistic models that explain the causes of BPSD include:

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

Anytime you see or hear about a patient with “agitation” or “change in behaviour”, you must have a broad differential diagnosis at all times! Even if you've known the patient for a long time, if there is some new change in behaviour, you also need to make a new set of differentials.

Depending on the physical exam and patient's symptoms, common investigations may include: CBC, electrolytes, extended electrolytes, urine culture, and imaging (e.g. - chest X-ray).

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.

Daily information and measures that should be captured include:

• The times medications are being administered for BPSD, and what response the individual has had to the medication
• Overall fluid intake and oral intake
• Bowel movements and urine output
• Sleep charting or Dementia Observation Charting (DOS)
• Vitals or orthostatic vitals
• Pain monitoring (e.g. - with movement or feeding)

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 using 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.

• It is not enough to just rely on subjective reports from nursing staff or physicians to determine a patient's level of agitation or behavioural changes
• BPSD symptoms are subjective, and thus should be charted in as objective of a way as possible.
• Thus, the Dementia Observational System (DOS) is an objective way of charting these behaviours
• In facilities that do not do a DOS, sleep charting might also be ordered as well.

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.^[12][13] 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,^[14] music therapy, therapeutic touch, bright light therapy, and aromatherapy.^[15] 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.

• Citalopram (best evidence), escitalopram, sertraline, and trazodone have comparable effects as antipsychotics, in reducing delusions, anxiety, and irritability/lability.^[24]
• In the elderly, it is particularly important to monitor for hyponatremia, and sodium levels should be drawn within 4 weeks. Trazodone has inconclusive evidence,^[25] though it is commonly used due to its sedating effects. There are some positive results in the use of trazodone for frontotemporal dementia.^[26]
• Mirtazapine is not an effective agent for treatment of BPSD, and may be associated with increased mortality risk.^[27]

• Risperidone (the 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 recently had conflicting evidence, as recent meta-analyses have found a strong placebo effect.^[28]
• Quetiapine and clozapine are they only antipsychotics that can be used in patients with parkinsonism (DLB or Parkinson's).
• Antipsychotics are only indicated 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.^[29]
• There are clear risks for increased all-cause mortality and stroke risk when antipsychotics are used, and the benefits must outweigh the risks.^[30] 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 for treatment. The risk of death is highest for haloperidol, and lowest for quetiapine.^[31] Antipsychotics also can bring on other side effects, including falls, metabolic side effects, hypotension, cognitive impairment, and pneumonia.

Inappropriate sexual behavior (ISB) can be an extremely disruptive form of BPSD, placing other individuals at risk, and cause distress for caregivers. No randomized control trials have investigated the use of treatment of ISB, but several different classes have been used.

One should consider a trial of tapering 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.