- Last edited on February 28, 2021
Behavioural and Psychological Symptoms of Dementia (BPSD)
Primer
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.
Prevalence
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]
Symptoms
Is It Really Agitation?
Be careful when using the word “agitation” in a clinical context, as this is thrown without understanding the meaning behind it. Agitation is inappropriate verbal, vocal, or motor activity that is not judged by an outside observer to result directly from apparent needs or confusion of the agitated individual.[3] This means you must always need to understand if there were environment triggers or behaviours behind the “agitation.”BPSD symptoms can be organized into 5 symptom clusters:
- Apathy (lack of initiative)
- Psychosis (delusions, hallucinations)
- Aggression/Agitation (verbal, physical)
- Hyperactivity (pacing, restlessness, disinhibition)
- Affective (dysphoria, elation irritability, anxiety)
Frequency of BPSD Symptoms in Alzheimer's
Adapted from: Lishman’s Organic Psychiatry (2007)Symptoms | Prevalence (%) |
---|---|
Misidentification syndrome | 10-20 |
Depression | 10-25 |
Hallucinations (visual > auditory)[4] | 20-30 |
Paranoid or delusional | 20-30 |
Agitation | 30-70 |
Wandering | 15-40 |
Aggression | 20-40 |
Anxiety | >50 |
Apathy | 15-80 |
Circadian rhythm disturbance | 30-80 |
Sundowning
“Sundowning” is a phenomenon where disruptive behavior from BPSD worsens in the late afternoon.[5] It is thought to occur due to alterations in circadian rhythms from neurodegeneration. The reported prevalence of sundowning varies greatly between different clinical settings and various dementia types. It is also important to note that sundowning can also occur in delirium as well.Pathophysiology
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:
- Unmet Needs Model (i.e. - the patient is unable to express their needs)
- Progressively Lowered Stress Threshold Model (i.e. - ability to deal with stress or stimuli is impaired as the neurodegeneration progresses)
- Antecedent-Behaviour-Consequence learning theory (ABC Model)
Differential Diagnosis
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.
BPSD Differential Diagnosis
Delirium | Look for acute changes and fluctuations, and do a thorough delirium work up if suspected. Infections such as UTIs can be frequent culprits. |
---|---|
Depression | Major depressive disorder can be difficult to identify in advanced dementia |
Pain | Pain can be either acute or chronic, and is frequently under-diagnosed. One must be vigilant and look for verbal and non-verbal cues.[7] If pain is properly managed and treated, this can improve agitation, mood, apathy, appetite, and reduce nighttime behaviours.[8] However, treating pain does not change baseline irritability. If pain is identified, a stepwise approach to treating pain is recommended, starting with: 1. Acetaminophen/NSAIDs 2. Extended release morphine 3. Buprenorphine transdermal patch 4. Pregabalin[9] |
Medical Triggers | • Dehydration (are they having adequate water intake?) • Constipation (when was their last bowel movement?) • Urinary tract or lung infections (any urinary symptoms, coughing, vital sign changes?) • Dental pain, infection, abscesses (has there been an oral exam?) • Musculoskeletal changes (include imaging to rule out fractures, osteoporosis/degenerative changes, bed sores, or other soft tissue injuries) • Acute neurological insults (e.g. - stroke, is there any facial droop or other neurological changes?) • Exacerbation of chronic conditions (e.g. - could there be cancer progression?) |
Environmental Triggers | Identify the presence of any enivronmental triggers, which can often worsen or exacerbate BPSD[10] • Excessive noise or stimulation • Lack of structure/routine • Inadequate lighting • Confusing surroundings • Excessive demands • Loneliness/boredom • Behaviour of others co-patients/residents • Change in caregivers • Vision (do they need glasses?) or hearing changes (do they have hearing aids?) |
Personality | • What was the individual's underlying temperament and personality before the behavioural changes? How much of this is their “baseline” self? |
The 4 B's
Mnemonic
For an easy mnemonic to remember common triggers for behavioural changes, think about the4 B's
of discomfort in older adults:[11]- Bowels: when was the patient’s last bowel movement?
- Bladder: when did they last urinate? Any urinary symptoms?
- Beverage: are they hungry or thirsty? Have they been offered preferred beverages or food?
- Bottom (to Top): a visual survey for obvious precipitants of distress and agitation
Investigations
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).
Management
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.
Antecedent, Behaviour, and Consequences (ABCs)
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.
Sample ABC Charting
Antecedent | Behaviour | Consequence | |
---|---|---|---|
April 20, 8:00 PM | Patient continuously asks to go to bathroom and calls for help | Pulls of undergarment and urinates on floor | Was told not to do this, brought to room, cleaned and changed |
April 23, 8:30 PM | Sitting at nursing station | Asks to go to bathroom repeatedly, begins yelling for help | RN engages patient, distracts and becomes quieter, until RN leaves, and the behaviour re-starts |
April 27, 8:20 PM | Sitting alone in corner | Calls out “help” repeatedly | Was asked what was wrong and staff spent some time with her until she calmed down, but then it started again |
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.
Dementia Observational System (DOS)
Dementia Observational System (DOS)
Name | Rater | Description | Download |
---|---|---|---|
Dementia Observational System (DOS) | Observer/Clinician | The Dementia Observational System (DOS) is a tool used to assess a person’s behaviour over a 24 hour cycle for up to 7 days to determine the occurrence, frequency, and duration of behaviours of concern. | Download |
Describe, Investigate, Create, Evaluate (DICE)
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.
The DICE Approach
Kales, et al. Assessment and management of behavioral and psychological symptoms of dementia. BMJ 350.7 (2015)Describe | Patient, behavior, environment, situation, target |
---|---|
Investigate | Medical problem, medications, caregiver causes, environment |
Create | Environment, behavioral, pharmacological interventions |
Evaluate | Effect, side-effects |
Treatment
Non-pharmacological
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.[14] 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.
Pharmacological
Antidepressants and antipsychotic medications are the most common medication classes used for BPSD. However, it is important to remember that not all symptoms of BPSD respond to medications, and a comprehensive non-pharmacological approach must be taken! If there are symptoms that can be targeted and treated pharmacologically, the medications should target the specific symptoms:
- Apathy: bupropion, modafinil, memantine, psychostimulants, dopamine agonists
- Affect (dysphoria, irritability, anxiety): antidepressants, anticonvulsants
- Psychosis: antidepressants, antipsychotics
- Physical aggression: antipsychotics, memantine, antidepressants
Symptoms and likelihood of medication response
Usually not responsive to medications | Can be responsive to medications |
---|---|
Simple wandering | Sleep disturbances |
Hiding | Anxiety |
Hoarding | Dysphoria and depressive symptoms |
Vocalizations | Apathy/withdrawal |
Inappropriate undressing | Hyperactivity |
Inappropriate defecation | Hallucinations |
Inappropriate urination | Physical/verbal aggression |
Repetitive activities | Sexually inappropriate behaviour |
Medication Classes for BPSD and Evidence
Medication/Class | Evidence |
---|---|
Memantine | • There is somewhat limited evidence for memantine, and prospective RCTs have been negative. |
Acetylcholinesterase inhbitors (AChEI) | • AChEIs are recommended as a treatment option for AD with cerebrovascular disease, dementia with Parkinson's disease, and mild to severe AD, but there is no recommendation for or against its use as a primary treatment for neuropsychiatric symptoms (i.e. - BPSD).[15] Many patients may already been on these medications as part of their disease treatment. • There is good first line evidence for the use of donepezil and rivastigmine in behavioural symptoms (especially hallucinations and agitation) related to Lewy Body Dementia (LBD).[16] It may also be helpful in managing symptoms of depression, anxiety, and apathy. |
AChEI plus memantine | • There is insufficient evidence to recommend for or against the combination of a ChEI and memantine together for neuropsychiatric symptoms of dementia.[17] |
Mood stabilizers | • Carbamazepine been shown to have some utility in treating BPSD.[18] There is no evidence for valproic acid |
Valproic acid | • Valproic acid should not be used for agitation and aggression in AD.[19] |
Other | • Other potential medications with some positive results include dextromethorphan-quinidine,[20] and prazosin.[21] |
Antidepressants
Citalopram (best evidence), escitalopram, sertraline, and trazadone have comparable effects as antipsychotics, in reducing delusions, anxiety, and irritability/lability.[22] In the elderly, it is particularly important to monitor for hyponatremia, and sodium levels should be drawn within 4 weeks. Trazodone has inconclusive evidence,[23] though it is commonly used due to its sedating effects. There are some positive results in the use of trazodone for frontotemporal dementia.[24]
Atypical antipsychotics
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 recently had conflicting evidence, as recent meta-analyses have found a strong placebo effect.[25] Quetiapine and clozapine are they only antipsychotics that can be used in patients with parkinsonism (LBD or Parkinson's).
Antipsychotics are 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.[26] There are clear risks for increased all-cause mortality and stroke risk when antipsychotics are used, and the benefits must outweigh the risks.[27] 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.[28] Antipsychotics also can bring on other side effects, including falls, metabolic side effects, hypotension, cognitive impairment, and pneumonia.
Antipsychotic Dosing
Antipsychotic | Starting dose (mg) | Frequency | Titrate by (mg) | Maximum daily dose (mg) | Notable side effects |
---|---|---|---|---|---|
Risperidone | 0.25 | daily/BID | 0.25 | 2 | EPS, gait disturbance, infection risk (UTI/URTI), peripheral edema, orthostatic hypotension, metabolic syndrome |
Olanzapine | 1.25 | HS/BID | 1.25-2.5 | 7.5 | EPS, gait disturbance, infection risk (UTI/URTI), peripheral edema, metabolic syndrome |
Loxapine | 2.5 | BID/TID | 2.5-5 | 25 | EPS |
Haloperidol | 0.25 | daily/BID | 0.25-0.5 | 2 | EPS |
Aripiprazole | 0.5 | daily | 0.5-1 | 10 | Insomnia, akathisia |
Quetiapine* | 12.5 | BID/TID/HS | 12.5-25 | 150 | Orthostatic hypotension, sedation, QTc prolongation, agitation, insomnia |
Typical and High Potency Antipsychotics Are Contraindicated in Lewy Body Dementia and Parkinson's
A severe sensitivity reaction occurs in an estimated 25-50% of Lewy Body Dementia (LBD) patients administered typical antipsychotic drugs (especially haloperidol) in the usual dose range.[29][30][31] This results in cognitive impairment, sedation, increased/irreversible acute onset of parkinsonism, or symptoms resembling neuroleptic malignant syndrome. If an antipsychotic must be used, then low potency atypical antipsychotics like clozapine or quetiapine should be used.[32]Inappropriate Sexual Behaviour (ISB)
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.
Non-pharmacological
Adapted from: De Giorgi, R. et al. (2016). Treatment of inappropriate sexual behavior in dementia. Current treatment options in neurology, 18(9), 41.Approach | Description |
---|---|
Environmental | Switching from a female to a male staff member, single rooms, and redirection may be helpful in mild cases. |
Behavioural | Consistent redirection and enhanced communication, distraction techniques (crafts, social activities), use of clothing with back zippers (can have ethical implications) |
Education | Caregiver education about sexuality, and changes associated with dementia can help. |
Pharmacological (Psychotropics)
Adapted from: De Giorgi, R. et al. (2016). Treatment of inappropriate sexual behavior in dementia. Current treatment options in neurology, 18(9), 41.Psychotropics | Description |
---|---|
Antidepressants | • SSRIs are common first line agents. • Tricyclic antidepressants, specifically clomipramine • Trazodone |
Anxiolytics | There is no evidence for the use of benzodiazepines in ISB, it may cause paradoxical reactions, and may worsen cognitive impairment. |
Antipsychotics | • Quetiapine • Haloperidol |
Anticonvulsants | • Gabapentin • Carbamazepine |
Cholinesterase inhibitors | • Donepezil |
Pharmacological (Hormonal and Antiandrogen)
Adapted from: De Giorgi, R. et al. (2016). Treatment of inappropriate sexual behavior in dementia. Current treatment options in neurology, 18(9), 41., and Joller P. et al. Approach to inappropriate sexual behaviour in people with dementia. Can Fam Physician. 2013;59(3):255-260.Hormonal and antiandrogen agents | Mechanism of action | Dosing | Potential adverse effects |
---|---|---|---|
Medroxyprogesterone (MPA)[33][34] | Indirectly decreases the level of testosterone by inhibiting the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). | • MPA 100 to 500 mg IM weekly, or • MPA 100mg PO daily | Fatigue, weight gain, hot or cold flashes, depression, elevated blood glucose, insomnia |
Cyproterone acetate (CPA)[35] | Synthetic progestin and antiandrogen that blocks androgen receptors | CPA 10 to 50mg PO daily | Gynecomastia, galactorrhea, worsening diabetes control, depression, osteoporosis, adrenal insufficiency on withdrawal, hepatotoxicity (liver enzymes should be checked first) |
Finasteride[36] | 5α-reductase inhibitor that blocks conversion of testosterone to dihydrotesterone | Finasteride 5mg PO daily | Gynecomastia, testicular pain, depression |
Estrogen[37] | Estrogens inhibit the secretion of LH and FSH, and decrease testosterone production. | • Estrogen (conjugated) 0.625 mg PO daily, or • Transdermal estrogen patch 0.5 to 0.10 mg daily | Weight gain, depression, gynecomastia, venous thromboembolism (VTE) |
Leuprolide[38] | Leuprolide is a gonadotropin-releasing hormone (GnRH) analog. It suppress testosterone production by stimulating the secretion of pituitary LH and FSH, with subsequent increase in estrogen levels and decrease of testosterone | Leuprolide acetate 7.5 mg IM qmonthly | Weight gain, bone pain, osteoporosis, mood changes, pituitary apoplexy (rare) |
Spironolactone[39] | Potassium-sparing diuretic with anti-androgenic properties, via blocking of androgen receptors | Spironolactone 75mg PO daily | Hyperkalemia, gynecomastia, change in hair growth, upper gastrointestinal ulcers, agranulocytosis |
Deprescribing
One should consider a trial of tapering and withdraw pharmacotherapy after 3 months of behavioural stability.
ECT
Guidelines
Behavioural and Psychological Symptoms of Dementia (BPSD) Guidelines
Guideline | Location | Year | Website | |
---|---|---|---|---|
Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD) | Canada | 2020 | - | Link |
Canadian Coalition for Seniors' Mental Health (CCSMH) Assessment and Treatment of Mental Health Issues in Long-Term Care | Canada | 2006, 2014 | • 2006 Guideline • 2014 Update | Link |
National Institute for Health and Care Excellence (NICE) | UK | 2018 | - | Link |
Treatment of Inappropriate Sexual Behavior in Dementia | UK | 2016 | - | Link |
American Psychiatric Association (APA) | USA | 2016 | - | Link |