Differences

This shows you the differences between two versions of the page.

Link to this comparison view

Both sides previous revision Previous revision
Previous revision
geri:dementia:1-bpsd [on July 4, 2019]
geri:dementia:1-bpsd [on February 2, 2024] (current)
psychdb [Deprescribing]
Line 2: Line 2:
 {{INLINETOC}} {{INLINETOC}}
 ===== Primer ===== ===== Primer =====
-**Behavioural and Psychological Symptoms of Dementia (BPSD)** will develop in more than 90% of individuals diagnosed with dementia.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17607801|Steinberg,​ M., Shao, H., Zandi, P., Lyketsos, C. G., Welsh‐Bohmer,​ K. A., Norton, M. C., ... & Tschanz, J. T. (2008). Point and 5‐year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study. International Journal of Geriatric Psychiatry: A journal of the psychiatry of late life and allied sciences, 23(2), 170-177.]])] 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.+**Behavioural and Psychological Symptoms of Dementia (BPSD)** will develop in more than 90% of individuals diagnosed with dementia.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17607801|Steinberg,​ M., Shao, H., Zandi, P., Lyketsos, C. G., Welsh‐Bohmer,​ K. A., Norton, M. C., ... & Tschanz, J. T. (2008). Point and 5‐year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study. International Journal of Geriatric Psychiatry: A journal of the psychiatry of late life and allied sciences, 23(2), 170-177.]])] 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 == == 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.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17607801|Steinberg,​ M., Shao, H., Zandi, P., Lyketsos, C. G., Welsh‐Bohmer,​ K. A., Norton, M. C., ... & Tschanz, J. T. (2008). Point and 5‐year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study. International Journal of Geriatric Psychiatry: A journal of the psychiatry of late life and allied sciences, 23(2), 170-177.]])] 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.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17607801|Steinberg,​ M., Shao, H., Zandi, P., Lyketsos, C. G., Welsh‐Bohmer,​ K. A., Norton, M. C., ... & Tschanz, J. T. (2008). Point and 5‐year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study. International Journal of Geriatric Psychiatry: A journal of the psychiatry of late life and allied sciences, 23(2), 170-177.]])]
 +
 <​HTML>​ <​HTML>​
 <script async src="​https://​pagead2.googlesyndication.com/​pagead/​js/​adsbygoogle.js"></​script>​ <script async src="​https://​pagead2.googlesyndication.com/​pagead/​js/​adsbygoogle.js"></​script>​
 +<!-- Leaderboard -->
 <ins class="​adsbygoogle"​ <ins class="​adsbygoogle"​
-     ​style="​display:​block; text-align:​center;"​ +     ​style="​display:​block"​
-     ​data-ad-layout="​in-article"​ +
-     ​data-ad-format="​fluid"+
      ​data-ad-client="​ca-pub-8020066590182443"​      ​data-ad-client="​ca-pub-8020066590182443"​
-     ​data-ad-slot="​3544422091"></​ins>​+     ​data-ad-slot="​1227446251"​ 
 +     ​data-ad-format="​auto"></​ins>​
 <​script>​ <​script>​
      ​(adsbygoogle = window.adsbygoogle || []).push({});​      ​(adsbygoogle = window.adsbygoogle || []).push({});​
Line 19: Line 20:
 </​HTML>​ </​HTML>​
 ===== Symptoms ===== ===== Symptoms =====
 +<callout type="​warning"​ title="​Is It Really Agitation?"​ icon="​true">​
 +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.[(Cohen-Mansfield Agitation Inventory (CMAI), p. 2 1992)] This means you must always need to understand if there were environment triggers or behaviours behind the "​agitation."​
 +</​callout>​
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
Line 29: Line 33:
 </​WRAP>​ </​WRAP>​
 <WRAP half column> <WRAP half column>
-<callout ​type="warning" title="​Is It Really Agitation?" ​icon="​true"​+<panel type="info" title="​Frequency of BPSD Symptoms in Alzheimer'​s" ​subtitle="​Adapted from: Lishman’s Organic Psychiatry (2007)"​ no-body="​true" ​footer=""​
-Be careful when using the word "agitation" ​in a clinical context, as this is thrown around by various clinical staff without understanding the meaning behind itAgitation 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.[(Cohen-Mansfield Agitation Inventory (CMAI), p2 1992)] This means you must always need to understand if there were environment triggers ​or behaviours behind the "​agitation."​ +^ Symptoms ​                                                                                                                                                                                                                                                                                                                                                                                                 ^ Prevalence (%)  ^ 
-</callout>+| Misidentification syndrome ​                                                                                                                                                                                                                                                                                                                                                                               | 10-20           | 
 +| Depression ​                                                                                                                                                                                                                                                                                                                                                                                               | 10-25           | 
 +| Hallucinations (visual > auditory)[([[https://​www.ncbi.nlm.nih.gov/pmc/articles/PMC6019263/|Linszen, M. M., Lemstra, A. W., Dauwan, M., Brouwer, R. M., Scheltens, P., & Sommer, I. E. (2018). Understanding hallucinations in probable Alzheimer'​s disease: Very low prevalence rates in a tertiary memory clinic. Alzheimer'​s & Dementia: DiagnosisAssessment & Disease Monitoring, 10, 358-362.]])]  | 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           | 
 +</panel>
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
 +
 +<callout type="​info"​ title="​Sundowning"​ icon="​true">​
 +"​Sundowning"​ is a phenomenon where disruptive behavior from BPSD worsens in the late afternoon.[([[https://​pubmed.ncbi.nlm.nih.gov/​26243434/​|Gnanasekaran,​ G. (2016). “Sundowning” as a biological phenomenon: current understandings and future directions: an update. Aging clinical and experimental research, 28(3), 383-392.]])] 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 [[cl:​1-delirium|delirium]] as well.
 +</​callout>​
  
 ===== Pathophysiology ===== ===== Pathophysiology =====
-Theoretical ​models that explain the causes of BPSD include: +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.[([[https://​pubmed.ncbi.nlm.nih.gov/​27298146/​|Sousa Alves, G., Ferrer Carvalho, A., de Amorim de Carvalho, L., Kenji Sudo, F., Ibiapina Siqueira-Neto,​ J., Oertel-Knochel,​ V., ... & Pantel, J. (2017). Neuroimaging findings related to behavioral disturbances in Alzheimer'​s disease: a systematic review. Current Alzheimer Research, 14(1), 61-75.]])] These are areas of the brain responsible for emotional regulation, self-awareness,​ and perception. Other cluster symptoms such as [[teaching:​apathy|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 needs) +  - **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) +  - **Progressively Lowered Stress Threshold Model** (i.e. - ability to deal with stress or stimuli is impaired ​as the neurodegeneration progresses
-  - [[geri:​dementia:​1-bpsd#​antecedent-behaviour-and-consequences-abcs|ABC Model]] ​(Antecedent-Behaviour-Consequence learning theory)+  - **Antecedent-Behaviour-Consequence learning theory** ([[geri:​dementia:​1-bpsd#​antecedent-behaviour-and-consequences-abcs|ABC Model]]
 +===== Differential Diagnosis ===== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See also main articles: **[[cl:​1-delirium|]],​ [[pain-medicine:​home]],​ and [[mood:​1-depression:​home|]]**</​alert>​
  
 +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.
  
-===== Differential Diagnosis ===== 
-<callout type="​success">​{{fa>​arrow-circle-right?​color=green}} See also main articles: **[[cl:​1-delirium|]],​ [[pain-medicine:​home]],​ and [[mood:​1-depression:​home|]]**</​callout>​ 
-<WRAP group> 
-<WRAP half column> 
-A broad differential diagnosis must be considered **at all times**: 
 <panel type="​info"​ title="​BPSD Differential Diagnosis"​ no-body="​true">​ <panel type="​info"​ title="​BPSD Differential Diagnosis"​ no-body="​true">​
-^ [[cl:​1-delirium|Delirium]] ​               | Look for acute changes and fluctuations,​ and do a thorough delirium work up if suspected. Infections such as [[https://​www.aafp.org/​afp/​2011/​1001/​p771.html|UTIs]] can be frequent culprits. ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  ​+^ [[cl:​1-delirium|Delirium]] ​            ​| Look for acute changes and fluctuations,​ and do a thorough delirium work up if suspected. Infections such as [[https://​www.aafp.org/​afp/​2011/​1001/​p771.html|UTIs]] can be frequent culprits. ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
-^ [[mood:​1-depression:​home|Depression]] ​                    ​| Major depressive disorder can be difficult to identify in advanced dementia ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   +^ [[mood:​1-depression:​home|Depression]] ​ | Major depressive disorder can be difficult to identify in advanced dementia, and additionally,​ evidence for treating depression in dementia is poor.[([[https://​pubmed.ncbi.nlm.nih.gov/​21764118/​|Banerjee,​ S., Hellier, J., Dewey, M., Romeo, R., Ballard, C., Baldwin, R., ... & Burns, A. (2011). Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre,​ double-blind,​ placebo-controlled trial. The Lancet, 378(9789), 403-411.]])] ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       | 
-^ [[pain-medicine:​home|Pain]] ​                   | Pain is frequently ​underdiagnosed,​ one must be vigilant and look for verbal and non-verbal cues.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​25373921|Flo,​ E., Gulla, C., & Husebo, B. S. (2014). Effective pain management in patients with dementia: benefits beyond pain?. Drugs & aging, 31(12), 863-871.]])] If pain is properly managed and treated, this can improve agitation, mood, apathy, appetite, and reduce nighttime behaviours.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3137923/​|Husebo,​ B. S., Ballard, C., Sandvik, R., Nilsen, O. B., & Aarsland, D. (2011). Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. Bmj, 343, d4065.]])] However, treating pain does not change baseline irritability. \\ \\ If pain is identified, a stepwise approach to treating pain is recommended,​ starting with: \\ 1. Acetaminophen \\ 2. Extended release morphine \\ 3. Buprenorphine transdermal patch \\ 4. Pregabalin[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23611363|Husebo,​ Bettina S., Clive Ballard, Jiska Cohen-Mansfield,​ Reinhard Seifert, and Dag Aarsland. "The response of agitated behavior to pain management in persons with dementia."​ The American Journal of Geriatric Psychiatry 22, no. 7 (2014): 708-717.]])] ​ | +^ Medications ​                           | Have you considered whether there could be significant drug-drug interactions,​ or drug-related side effects that are causing behavioural changes? Always do a review of medications when considering changes in behaviours. ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
-^ Medical Triggers ​       | • Dehydration\\ • Constipation\\ • Urinary or chest infection\\ • Dental pain/infection\\ • Pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               +^ [[pain-medicine:​home|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.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​25373921|Flo,​ E., Gulla, C., & Husebo, B. S. (2014). Effective pain management in patients with dementia: benefits beyond pain?. Drugs & aging, 31(12), 863-871.]])] If pain is properly managed and treated, this can improve agitation, mood, apathy, appetite, and reduce nighttime behaviours.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3137923/​|Husebo,​ B. S., Ballard, C., Sandvik, R., Nilsen, O. B., & Aarsland, D. (2011). Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. Bmj, 343, d4065.]])] 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 ​[[meds:​opioids:​morphine|morphine]] ​\\ 3. [[meds:​opioids:​buprenorphine|Buprenorphine]] transdermal patch \\ 4. [[meds:​mood-stabilizers-anticonvulsants:​pregabalin|Pregabalin]][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23611363|Husebo,​ Bettina S., Clive Ballard, Jiska Cohen-Mansfield,​ Reinhard Seifert, and Dag Aarsland. "The response of agitated behavior to pain management in persons with dementia."​ The American Journal of Geriatric Psychiatry 22, no. 7 (2014): 708-717.]])] ​ | 
-^ Environmental Triggers ​ | Identify the presence of any enivronmental triggers, which can often worsen or exacerbate BPSD[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16816009|Lyketsos,​ C. G., Colenda, C. C., Beck, C., Blank, K., Doraiswamy, M. P., Kalunian, D. A., & Yaffe, K. (2006). Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. The American journal of geriatric psychiatry, 14(7), 561-573.]])]\\ • Excessive noise or stimulation\\ • Lack of structure/​routine\\ • Inadequate lighting\\ • Confusing surroundings\\ • Excessive demands\\ • Loneliness/​boredom\\ • Behaviour of others ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |+^ Medical Triggers ​                      ​| • Dehydration ​or thirst (**are they having adequate fluid or water intake?**)\\ • Constipation ​(**when was their last bowel movement?​**)\\ • Retention (**are there are urinary retention issues?**)\\ • Urinary ​tract or lung infections (**any urinary symptoms, coughing, vital sign changes?**)\\ • Dental paininfection, abscesses (**has there been an oral exam?**)\\ • Ear pain, ear wax impaction, ear infection, abscesses (**has there been an ear exam?**)\\ • Musculoskeletal changes (**imaging to rule out fractures, osteoporosis/​degenerative changes, bed sores, or other soft tissue injuries?​**)\\ • Acute neurological insults (**is there any facial droop or other neurological changes suggestive of a [[neurology:​approach-stroke|stroke]]?​**)\\ • Exacerbation of chronic conditions (**could there be cancer progression?​**) ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
 +^ Environmental Triggers ​                ​| Identify the presence of any enivronmental triggers, which can often worsen or exacerbate BPSD[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16816009|Lyketsos,​ C. G., Colenda, C. C., Beck, C., Blank, K., Doraiswamy, M. P., Kalunian, D. A., & Yaffe, K. (2006). Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. The American journal of geriatric psychiatry, 14(7), 561-573.]])]\\ • 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?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
 </​panel>​ </​panel>​
-</​WRAP>​ 
-<WRAP half column> 
-====The 4 B'​s==== 
-Also think about identifying the "4 B'​s"​ of discomfort in older adults:​[([[https://​www.bmj.com/​rapid-response/​2011/​11/​03/​rather-analgesia-focus-bowels-bladder-beverage-and-bottom|Rather than analgesia focus on "​Bowels,​ Bladder, Beverage and Bottom” Dylan G Harris]])] 
  
-  ​- **Bowels**: when was the patient’s last bowel movement+==== The 4 B's ==== 
 +<callout icon="​fa fa-lightbulb-o"​ type="​success"​ title="​Mnemonic">​ 
 +For an easy mnemonic to remember common triggers for behavioural changes, think about the **''​4 B'​s''​** of discomfort in older adults:​[([[https://​www.bmj.com/​rapid-response/​2011/​11/​03/​rather-analgesia-focus-bowels-bladder-beverage-and-bottom|Rather than analgesia focus on "​Bowels,​ Bladder, Beverage and Bottom” Dylan G Harris]])] 
 +  ​- **Bowels**: when was the patient’s last bowel movement?
   - **Bladder**:​ when did they last urinate? Any urinary symptoms?   - **Bladder**:​ when did they last urinate? Any urinary symptoms?
   - **Beverage**:​ are they hungry or thirsty? Have they been offered preferred beverages or food?   - **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   - **Bottom** (to Top): a visual survey for obvious precipitants of distress and agitation
 +</​callout>​
  
-</WRAP+==== Investigations ==== 
-</WRAP>+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). 
 + 
 +<​HTML>​ 
 +<script async src="​https://​pagead2.googlesyndication.com/​pagead/​js/​adsbygoogle.js"></​script>​ 
 +<!-- Leaderboard --> 
 +<ins class="​adsbygoogle"​ 
 +     ​style="​display:​block"​ 
 +     ​data-ad-client="​ca-pub-8020066590182443"​ 
 +     ​data-ad-slot="​1227446251"​ 
 +     ​data-ad-format="​auto"></​ins>​ 
 +<​script>​ 
 +     ​(adsbygoogle = window.adsbygoogle || []).push({});​ 
 +</script
 +</HTML>
  
 ===== Management ===== ===== 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.+<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See also: **[[https://​pubmed.ncbi.nlm.nih.gov/​29338602/​|Davies,​ S. J. et al. (2018). Sequential drug treatment algorithm for agitation and aggression in Alzheimer’s and mixed dementia. Journal of Psychopharmacology,​ 32(5), 509-523.]]** 
 +</​alert>​ 
 + 
 +Managing BPSD requires a thorough assessment, involving multiple sources of information,​ including a medical history, social history, personal history, and habits. All medications must be reviewed, and its role and indication reassessed. Family and caregivers also need to be interviewed. There also needs to be an adequate physical exam, bloodwork, and urine cultures ​if appropriate. 
 + 
 +==== Scales ==== 
 +Neuropsychiatric scales to assess behaviours and symptoms are critical to ensuring the symptoms are properly tracked and documented, to track changes before and after a treatment plan. Either the Cohen-Mansfield Agitation Inventory (CMAI) or Neuropsychiatric Inventory (NPI) should be completed for any patient experiencing BPSD. 
 + 
 +<panel title="​BPSD Scales"​ no-body="​true">​ 
 +<​mobiletable 1> 
 +^ Name                                                      ^ Rater                ^ Description ​                                                                                                                                                                                                                                                                                                                                                                       ^ Download ​                                                                         ^ 
 +^ Cohen-Mansfield Agitation Inventory (CMAI) ​               | Clinician/​Caregiver ​ | The CMAI is a 29-item scale to systematically assess agitation and neuropsychiatric behaviours in dementia. Each item is rated on a 7-point scale ranging from “Never” to “Several times per hour”. ​                                                                                                                                                                               | {{ :​geri:​dementia:​cohen-mansfield_agitation_inventory_cmai_short.pdf |Download}} ​ | 
 +^ Neuropsychiatric Inventory (NPI)                          | Clinician ​           | The [[http://​npitest.net/​download.html|Neuropsychiatric Inventory (NPI)]] is the original interview developed to provide a means of assessing neuropsychiatric symptoms and psychopathology of patients with Alzheimer’s disease and other neurodegenerative disorders. ​                                                                                                           | {{ :​geri:​dementia:​npi-original.pdf |Download}} ​                                   | 
 +^ Neuropsychiatric Inventory Nursing Home Version (NPI-NH) ​ | Clinician/​Caregiver ​ | The NPI-NH was derived from the Neuropsychiatric Inventory (NPI), which was originally developed for the assessment of neuropsychiatric symptoms and psychopathology in community-dwelling patients where information was obtained from family caregivers. The content of the questions of the NPI and NPI-NH are identical but have been rephrased appropriately for caregivers. ​ | {{ :​geri:​dementia:​npi-nh.pdf |Download}} ​                                         | 
 +^ Neuropsychiatric Inventory-Questionnaire (NPI-Q) ​         | Clinician/​Caregiver ​ | The NPI-Q is a questionnaire completed by informants. The NPI-Q differs from the standard NPI in several ways. It is given as a 2-page self-administered questionnaire,​ as opposed to an interview. The NPI-Q is designed to be completed within 5 minutes. ​                                                                                                                       | {{ :​geri:​dementia:​npi-q.pdf |Download}} ​                                          | 
 +</​mobiletable>​ 
 +</​panel>​ 
 + 
 +==== Daily Checks ==== 
 +Daily information and measures that should be captured during each visit with a patient with BPSD should include: 
 +  - The times medications are being administered for BPSD, and what response the individual has had to the medication 
 +  - Overall oral (solids and liquids) intake 
 +  - Bowel movements and urine output 
 +  - Sleep charting or Dementia Observation Charting (DOS) 
 +  - Vitals and/or orthostatic vitals 
 +  - Pain monitoring (e.g. - with movement or feeding) 
 +  - Overall amount of as needed (prn) medication use 
 +  - Review of overnight and previous day's behaviours with staff
  
 ==== Antecedent, Behaviour, and Consequences (ABCs) ==== ==== Antecedent, Behaviour, and Consequences (ABCs) ====
-It can often be helpful to break down the BPSD into ABC (**A**ntecedent,​ **B**ehaviour,​ and **C**onsequences) 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.+<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See also main article: **[[teaching:​behavioural-modification|]]** 
 +</​alert>​ 
 +It can often be helpful to break down the BPSD into ABC (**A**ntecedent,​ **B**ehaviour,​ and **C**onsequences) 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.
  
 <panel type="​info"​ title="​Sample ABC Charting"​ no-body="​true">​ <panel type="​info"​ title="​Sample ABC Charting"​ no-body="​true">​
-!^                   ^ Antecedent ​                                                     ^ Behaviour ​                                                  ^ Consequence ​                                                                                                  ^+<​mobiletable 1> 
 +^                    ^ 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 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 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  | ^ 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  |
 +</​mobiletable>​
 </​panel>​ </​panel>​
  
Line 83: Line 147:
  
 ==== Dementia Observational System (DOS) ==== ==== Dementia Observational System (DOS) ====
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​
 +See also: **[[https://​brainxchange.ca/​BSODOS|Behavioural Supports Ontario: Dementia Observation System (BSO-DOS©) Tool Kit]]**
 +</​alert>​
 +
 +  * The **Dementia Observational System (DOS)** is an objective way of charting dementia behaviours
 +  * In facilities that do not do a DOS, sleep charting might also be ordered as well.
 +  * 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, and this is where the value of the DOS comes in.
 +  * BPSD symptoms are subjective, and thus should be charted in as objective of a way as possible.
 <panel title="​Dementia Observational System (DOS)" no-body="​true">​ <panel title="​Dementia Observational System (DOS)" no-body="​true">​
-!^Name                                               ^ Rater      ^ Description ​                                                                                                                                                                                  ^ Download ​ ^+<​mobiletable 1> 
 +^ 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. ​     | {{ :​geri:​dementia:​dementia_observational_system_dos_tool.pdf |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. ​     | {{ :​geri:​dementia:​dementia_observational_system_dos_tool.pdf |Download}} ​      |
 +</​mobiletable>​
 </​panel>​ </​panel>​
  
 ==== Describe, Investigate,​ Create, Evaluate (DICE)==== ==== Describe, Investigate,​ Create, Evaluate (DICE)====
-The [[http://www.programforpositiveaging.org/​diceapproach/|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.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​25731881|Assessment and management of behavioral and psychological symptoms of dementia]])][([[https://​psychnews.psychiatryonline.org/​doi/​full/​10.1176/​appi.pn.2014.6a7|‘DICE’ Rolls to New Approach for Treating Dementia Symptoms]])] 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 **[[https://diceapproach.com/|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.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​25731881|Assessment and management of behavioral and psychological symptoms of dementia]])][([[https://​psychnews.psychiatryonline.org/​doi/​full/​10.1176/​appi.pn.2014.6a7|‘DICE’ Rolls to New Approach for Treating Dementia Symptoms]])] The evidence for non-pharmacological approaches to BPSD is better than the evidence for antipsychotics,​ and exceedingly better than for other classes of medication.
  
 <panel type="​info"​ title="​The DICE Approach"​ subtitle="​Kales,​ et al. Assessment and management of behavioral and psychological symptoms of dementia. BMJ 350.7 (2015)"​ no-body="​true">​ <panel type="​info"​ title="​The DICE Approach"​ subtitle="​Kales,​ et al. Assessment and management of behavioral and psychological symptoms of dementia. BMJ 350.7 (2015)"​ no-body="​true">​
-^ Describe ​    ​| ​Patient, behavior, ​environment,​ situation, target ​           ​+^ Describe ​    ​| ​Thoroughly describe and accurately characterize the symptoms and the contexts in which they occur. This description should come from a discussion with the caregiver and the person with dementia (if possible). For exampleif the behavior ​is agitationit's important to determine the actual behaviour) (e.g. - did the patient strike the caregiver during a bath? Was the water too hot? How was the caregiver talking to and approaching the patient? ​                                                                                                                                                                                                                                                                                                                                                                                                           ​
-^ Investigate ​ | Medical problem, medications,​ caregiver ​causesenvironment  ​+^ Investigate ​ | Once the symptoms are clearly describedthe clinician then needs to identify, or exclude, possible underlying and modifiable causes. These can include unmet needs (e.g. - fear, insufficient sleep, a need for eyeglasses or hearing aids), or acute medical problems (e.g. - anemia, urinary tract infection, or constipation). Current ​medications ​should be evaluatedand blood tests and urinalysis ordered if needed. Poor sleep habits and boredom also should be considered, along with the any caregiver's relationship with the patientincluding caregiver stress or depression that could exacerbate the patient'​s behaviours. ​                                                                                                                                                                                                                            
-^ Create ​      ​| ​Environmentbehavioralpharmacological interventions ​                    +^ Create ​      ​| ​In this step everyone collaborates to create and implement a treatment plan. Treatments can be either non-pharmacologic (behaviouralenvironmentalor a combination) or pharmacologic. Priority should be given to treating physical problems, such as antibiotics for a urinary tract infection, or discontinuing drugs that cause behavioural side effects. Providers should brainstorm behavioural and environmental approaches with caregivers and other members of the care team, which could include a visiting nurse or occupational therapist. The 5 domains of general strategies include: (1) educating the caregiver; (2) improving communication between the caregiver and patient; (3) creating meaningful activities for the patient; (4) simplifying tasks and establishing structured routines; and (5) ensuring safety and enhancing the environment.  ​
-^ Evaluate ​    ​| ​Effectside-effects ​                                        |+^ Evaluate ​    ​| ​The final step is to evaluate whether the strategies have been implemented and have had the desired effects. Since behaviours fluctuate over the course of dementiaongoing monitoring is essential: Caregivers can learn triggers for unwanted behaviors and to learn to spot these triggers before the symptoms fully develop. ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
 </​panel>​ </​panel>​
 +
 +==== Physical. Intellectual. Emotional. Capabilities. Environment. Social. (P.I.E.C.E.S). ====
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​
 +See also: **[[https://​www.youtube.com/​watch?​v=BYNfAQ7-E4Q&​list=PLws0NwJdLuYSj1vmAKd17GmpBphub7Up0|P.I.E.C.E.S. Step-by-Step Video]]**
 +</​alert>​
 +
 +**[[https://​pieceslearning.com/​|P.I.E.C.E.S.]] (Physical. Intellectual. Emotional. Capabilities. Environment. Social.)** is a non-pharmacological assessment tool used by healthcare professionals to help them determine causes for behavioural and psychological symptoms associated with dementia. In brief, in P.I.E.C.E.S.,​ the key questions to ask are:
 +  - What are the priority concerns; is it a change for the Person?
 +    * For each priority concern(s), ask; is it a change for the Person?
 +    * Avoid making assumptions and moving too quickly to actions before having a shared understanding
 +    * Language has to be clear, respectful, and objective
 +    * Priority concerns will vary over time; what are we seeking to understand now?
 +  - What are the **RISKS** and possible contributing factors (PIECES)?
 +      * ''​R''​ - Roaming (e.g. searching, seeking exit)
 +      * ''​I''​ - Imminent harm (Frailty, Falls, Fire, Firearms)
 +      * ''​S''​ - Suicide Ideation
 +      * ''​K''​ - Kinship relationships (risk of harm by the Person or to the Person by others; including avoidance of the Person)
 +      * ''​S''​ - Substance use
 +      * ''​S''​ - Self-neglect (a person'​s capability to care for self, for which there could be many contributing factors)
 +      * ''​S''​ - Safe Driving
 +      * ''​S''​ - Security
 +  - What are the actions?
 +
 +<panel type="​info"​ title="​P.I.E.C.E.S."​ subtitle=""​ no-body="​true"​ footer="">​
 +^ P - Physical causes for behaviours ​                             | There are a number of possible physical causes that may trigger a behaviour so time is required to eliminate or at least determine which, if any, of the following physical elements might be causing a reaction:\\ \\ • Pain (such as arthritis).\\ • Sensory loss (poor eyesight, poor hearing).\\ • Difficulty walking.\\ • Temperature – cold, hot.\\ • Medication – what are they taking – anything new or anything recently discontinued? ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
 +^ I - Intellectual causes for behaviours ​                         | Due to the impact dementia has on the brain, there are intellectual impairments that individuals with dementia deal with that can cause agitation or other behaviours. Healthcare professionals refer to them as the Seven A’s which help explain the frustration a patient faces:\\ \\ 1. **Anosognosia** is the lack of insight or awareness. The person with dementia does not know they have dementia and they believe they are fine. “There’s nothing wrong with me.”\\ 2. **Amnesia** is the loss of memories such as facts, experiences or information. The patient may know who they are but has trouble learning new information or forming new memories.\\ 3. **Altered Perception** is the inability to recognize themselves – their own reflection. Living in the past – living 25 years in the past becomes their reality.\\ 4. **[[neurology:​approach-aphasia|Aphasia]]** is a problem with language. There are four kinds: (1) //​Expressive//:​ know what you want to say but can’t say what you mean, (2), //​Receptive//:​ hear the voice or see the print but can’t make sense of the words, (3) //Anomic//: trouble using the correct word for places, object or events, (4) //Global//: can’t speak, understand speech, read or write.\\ 5. **[[teaching:​apathy|Apathy]]** is the absence or suppression of interest or motivation.\\ 6. **Agnosia** is the loss of the ability to recognize objects, faces, voices or places, but still have an ability to think, speak and interact with the world normally.\\ 7. **[[neurology:​approach-apraxia|Apraxia]]** is a motor speech disorder where messages from the brain to the mouth are disrupted. The person is unable to move their mouth, lips or tongue to the right place to make sounds correctly even though their muscles are not weak.  |
 +^ E - Emotional causes for behaviours ​                            | How is the person feeling in their body? Potential emotional causes for behavioural issues include [[anxiety:​home|anxiety]] and [[mood:​1-depression:​home|depression]].\\ \\ Everyone has a baseline level of anxiety they can withstand. For a person with dementia, their perceptual disconnect impacts their threshold for anxiety. Their world can be frightening which heightens their state of anxiety. \\ \\ If you imagine that the objects they see are distorted, language doesn’t sound the same, or they may not recognize their own reflection, this altered state can impact their mood which in turn affects their behaviours.\\ \\ Anxiety is fueled by the fact that an individual with dementia has no control over their world – they can no longer navigate their time. Instead, they must rely on others to decide their day and schedule their activities for them.\\ \\ Behaviour(s) caused by anxiety may include being in a general state of upset or shadowing (following the caregiver around constantly). ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |
 +^ C - Capabilities (How they affect behaviour) ​                   | Caregivers need to assess what the individual with dementia is and is not capable of doing and then create opportunities for him or her to help themselves. On some level the individual with dementia is aware of their limitations,​ but if you need to replace some objects with unbreakable ones, make them as safe and ‘adult’ as possible – not childish.\\ \\ There is a risk of caregivers doing too much for the person with dementia. Don’t assume they can’t do things for themselves. Tasks may take longer and they may not remember the order of things but they are still able to perform acts such as dressing themselves.\\ \\ Create a list with the proper order of garments, put it on the wall, and point to the list so your loved one can follow it and dress themselves. If followed repeatedly, day after day, their “procedural body memory” will take over and your loved one will look for the list to get dressed. It can become a routine, but this requires consistency. ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |
 +^ E - Environment (How does their environment affect behaviour?​) ​ | Take a fresh look around the environment,​ and think about the following:​\\ • Eliminate clutter.\\ • Create clear, open and safe spaces to walk around in and be able to touch things without fear.\\ • Is it too hot or too cold? Check the room and water temperature.\\ • Is the room properly lit? Is it too bright, or too dark? Be aware that darkness can create shadows. Shadows can be frightening and may increase falls.\\ • Too many people or too much noise can cause confusion and anxiety, which can manifest as a behaviour such as shouting or agitation. ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
 +^ S - Social (How does social activity affect behaviour?​) ​        | The social aspect is all about the person – who they were. It’s very important. A person with dementia may not be able to express themselves as they once did, but their ‘person’ has not left with the disease.\\ \\ The Montessori method for dementia programming can be very effective for working with patients – the method’s philosophy is: We define ourselves by the activities we do. The activities are important, but the ability to have activities that hold meaning for us is very important.\\ \\ The challenge is to create opportunities that still have meaning for the person with dementia when their cognitive abilities are compromised. It requires planning, careful observation and thought.\\ \\ The most effective interventions are built on ‘who’ the person was. So, the best thing you can do for your loved one with dementia is to create a document that tells other people who your loved one was. It should include the highlights, low moments and difficulties faced throughout their lives. ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |
 +</​panel>​
 +
  
 ===== Treatment ===== ===== Treatment =====
  
 ==== Non-pharmacological ==== ==== 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.[([[https://www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4676992/|OliveiraAM. D., Radanovic, M., Mello, P. C. H. D., Buchain, P. C., Vizzotto, ​A. D. B., Celestino, D. L., ... & Forlenza, O. V. (2015). Nonpharmacological ​interventions ​to reduce behavioral ​and psychological symptoms of dementia: a systematic review. ​BioMed research international2015.]])] The challenges with interpreting the efficacy of non-pharmacological interventions is they are often small in sample sizehave 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.+<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See also: **[[https://pubmed.ncbi.nlm.nih.gov/​31610547/|WattJ. A. et al. (2019). Comparative efficacy of interventions ​for aggressive ​and agitated behaviors in dementia: a systematic review ​and network meta-analysisAnnals of internal medicine171(9), 633-642.]]** 
 +</​alert>​
  
 +Non-pharmacological interventions are a cornerstone of managing BPSD, and must not be forgotten! This includes physical exercises and activity programs,​[([[https://​pubmed.ncbi.nlm.nih.gov/​33818342/​|Kouloutbani,​ K., Venetsanou, F., Markati, A., Karteroliotis,​ K. E., & Politis, A. (2021). The effectiveness of physical exercise interventions in the management of neuropsychiatric symptoms in dementia patients: a systematic review. International psychogeriatrics,​ 1-14.]])] music therapy, therapeutic touch, [[teaching:​phototherapy|bright light therapy]], and aromatherapy.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4676992/​|Oliveira,​ A. M. D., Radanovic, M., Mello, P. C. H. D., Buchain, P. C., Vizzotto, A. D. B., Celestino, D. L., ... & Forlenza, O. V. (2015). Nonpharmacological interventions to reduce behavioral and psychological symptoms of dementia: a systematic review. BioMed research international,​ 2015.]])] 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 ==== 
-It is important that not all symptoms of BPSD respond to medications,​ and a comprehensive non-pharmacological approach must be taken! 
  
 +==== Pharmacological ====
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
-== Are the Symptoms Responsive to Medications?​ == +  * Antidepressants and antipsychotic medications are the most common medication classes used for BPSD.  
-<panel type="​info"​ title="​Symptoms ​and Medication Response"​ no-body="​true">​ +  * 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: 
-^ Usually not responsive ​ ^ Can be responsive ​  ^ +  - **Apathy**: [[meds:​antidepressants:​ndri:​bupropion|bupropion]],​ [[meds:​stimulants:​modafinil|modafinil]],​ [[meds:​dementia:​memantine|memantine]],​ psychostimulants ([[meds:​stimulants:​amphetamine:​home|amphetamine]],​ [[meds:​stimulants:​2-methylphenidate:​home|methylphenidate]]),​ [[meds:​dopamine-agonists:​home|dopamine agonists]] 
-Simple wandering ​                     ​Sleep disturbances ​                | +  ​- **Affect (dysphoria, irritability,​ anxiety)**: [[meds:​antidepressants:​home|antidepressants]] ([[meds:​antidepressants:​ssri:​home|SSRIs]], [[meds:​antidepressants:​snri:​home|SNRIs]], [[meds:​antidepressants:​sari:​trazodone|trazodone]]),​ [[meds:​mood-stabilizers-anticonvulsants:​home|anticonvulsants]] ([[meds:​mood-stabilizers-anticonvulsants:​carbamazepine|carbamazepine]],​ [[meds:​mood-stabilizers-anticonvulsants:​pregabalin|pregabalin]],​ [[meds:​mood-stabilizers-anticonvulsants:​gabapentin|gabapentin]]) 
-Hiding ​                               ​Anxiety ​                           ​+  - **Psychosis**:​ [[meds:​antipsychotics:​home|antipsychotics]] (risperidone),​ antidepressants (SSRIs, SNRIs) 
-| Hoarding ​                             | Dysphoria and depressive symptoms ​ | +  - **Physical aggression**: antipsychotics (risperidone),​ memantine, antidepressants (SSRIs, SNRIs) 
-Vocalizations ​                        Apathy/​withdrawal ​                 ​| +  * [[meds:​pharmacology:​placebo-effect|Placebo response rates]] in BPSD medication trials can be as high as 40%, underscoring the importance of the psychosocial environment on behaviours.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2647149/​|Liperoti, R., Pedone, C., & Corsonello, A. (2008). Antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD). Current neuropharmacology,​ 6(2), 117–124.]])] 
-Inappropriate undressing ​             ​Hyperactivity ​                     ​| +    * Behaviours may also spontaneously remit during disease progression. 
-| Inappropriate defecation ​             | Hallucinations ​                    +
-Inappropriate urination ​              ​| ​Physical/​verbal ​aggression ​        | +
-Repetitive activities ​                | Sexually inappropriate behaviour ​  +
-</​panel>​+
 </​WRAP>​ </​WRAP>​
-<WRAP half column> 
-== Target the Symptoms == 
-If there are symptoms that can be targeted and treated, the treatment should also 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 
  
 +<WRAP half column>
 +<panel type="​info"​ title="​Symptoms and likelihood of medication response"​ no-body="​true">​
 +<​mobiletable 1>
 +^ 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 ​  |
 +</​mobiletable>​
 +</​panel>​
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
  
-== Antidepressants ​== +<panel type="​info"​ title="​Medication Classes for BPSD and Evidence"​ subtitle=""​ no-body="​true"​ footer="">​ 
-Citalopram (best evidence), escitalopram,​ sertraline, and trazadone ​have comparable effects as antipsychotics,​ in reducing delusions, anxiety, and irritability/​lability.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23083438|Seitz,​ D. P., Gill, S. S., Herrmann, N., Brisbin, S., Rapoport, M. J., Rines, J., ... & Conn, D. K. (2013). Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review. International Psychogeriatrics,​ 25(2), 185-203.]])] In the elderly, it is particularly important to monitor for hyponatremia,​ and sodium levels should be drawn within 4 weeks. [[meds:​antidepressants:​sari:​trazodone|Trazodone]] has inconclusive evidence,​[([[http://​www.cmaj.ca/​content/​190/​47/​E1376|Watt,​ J. A., Gomes, T., Bronskill, S. E., Huang, A., Austin, P. C., Ho, J. M., & Straus, S. E. (2018). Comparative risk of harm associated with trazodone or atypical antipsychotic use in older adults with dementia: a retrospective cohort study. CMAJ, 190(47), E1376-E1383.]])] though it is commonly used due to its sedating effects. There are some positive results in the use of trazodone for [[geri:​dementia:​frontotemporal|frontotemporal dementia]].[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​15178953|Lebert,​ F., Stekke, W., Hasenbroekx,​ C., & Pasquier, F. (2004). Frontotemporal dementia: a randomised, controlled trial with trazodone. Dementia and Geriatric Cognitive Disorders, 17(4), 355-359.]])]+<​mobiletable 1> 
 +^ Medication/​Class ​                       ^ Evidence ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ^ 
 +^ Antidepressants ​                        | • [[meds:​antidepressants:​sari:​trazodone|Trazodone]] may help decrease insomnia, but it should be used with caution given the risk for orthostatic hypotension.[([[https://​pubmed.ncbi.nlm.nih.gov/​24495406/​|Camargos,​ E. F., Louzada, L. L., Quintas, J. L., Naves, J. O., Louzada, F. M., & Nóbrega, O. T. (2014). Trazodone improves sleep parameters in Alzheimer disease patients: a randomized, double-blind,​ and placebo-controlled study. The American Journal of Geriatric Psychiatry, 22(12), 1565-1574.]])]\\ • [[meds:​antidepressants:​ssri:​citalopram|Citalopram]] (best evidence), ​[[meds:​antidepressants:​ssri:​escitalopram|escitalopram]][[meds:​antidepressants:​ssri:​sertraline|sertraline]], and trazodone ​have comparable effects as antipsychotics,​ in reducing delusions, anxiety, and irritability/​lability.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23083438|Seitz,​ D. P., Gill, S. S., Herrmann, N., Brisbin, S., Rapoport, M. J., Rines, J., ... & Conn, D. K. (2013). Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review. International Psychogeriatrics,​ 25(2), 185-203.]])]\\ • In the elderly, it is particularly important to monitor for hyponatremia,​ and sodium levels should be drawn within 4 weeks. [[meds:​antidepressants:​sari:​trazodone|Trazodone]] has inconclusive evidence,​[([[http://​www.cmaj.ca/​content/​190/​47/​E1376|Watt,​ J. A., Gomes, T., Bronskill, S. E., Huang, A., Austin, P. C., Ho, J. M., & Straus, S. E. (2018). Comparative risk of harm associated with trazodone or atypical antipsychotic use in older adults with dementia: a retrospective cohort study. CMAJ, 190(47), E1376-E1383.]])] though it is commonly used due to its sedating effects. There are some positive results in the use of trazodone for [[geri:​dementia:​frontotemporal|frontotemporal dementia]].[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​15178953|Lebert,​ F., Stekke, W., Hasenbroekx,​ C., & Pasquier, F. (2004). Frontotemporal dementia: a randomised, controlled trial with trazodone. Dementia and Geriatric Cognitive Disorders, 17(4), 355-359.]])]\\ • [[meds:​antidepressants:​nassa:​mirtazapine|Mirtazapine]] is not an effective agent for treatment of BPSD, and may be associated with increased mortality risk.[([[https://​doi.org/​10.1016/​S0140-6736(21)01210-1|Banerjee,​ S., Stirling, S., Shepstone, L., Swart, A. M., Telling, T., Ballard, C., ... & High, J. (2021). Study of mirtazapine for agitated behaviours in dementia (SYMBAD): a randomised, 1 double-blind,​ placebo-controlled trial. The Lancet.]])] ​ | 
 +^ 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).[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3980908/​|Herrmann,​ N., Lanctôt, K. L., & Hogan, D. B. (2013). Pharmacological recommendations for the symptomatic treatment of dementia: the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 2012. Alzheimer'​s research & therapy, 5(1), S5.]])] Many patients may already been on these medications as part of their disease treatment. \\ • There is good first line evidence for the use of [[meds:​dementia:​donepezil|donepezil]] and [[meds:​dementia:​rivastigmine|rivastigmine]] in behavioural symptoms (especially hallucinations and agitation) related to [[geri:​dementia:​lewy-body|]].[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4772820/​|Matsunaga,​ S., Kishi, T., Yasue, I., & Iwata, N. (2016). Cholinesterase inhibitors for Lewy body disorders: a meta-analysis. International Journal of Neuropsychopharmacology,​ 19(2).]])] 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.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3980908/​|Herrmann,​ N., Lanctôt, K. L., & Hogan, D. B. (2013). Pharmacological recommendations for the symptomatic treatment of dementia: the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 2012. Alzheimer'​s research & therapy, 5(1), S5.]])] ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | 
 +^ Mood stabilizers ​                       | • Carbamazepine been shown to have some utility in treating BPSD.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​9433339|Tariot,​ P. N., Erb, R., Podgorski, C. A., Cox, C., Patel, S., Jakimovich, L., & Irvine, C. (1998). Efficacy and tolerability of carbamazepine for agitation and aggression in dementia. American Journal of Psychiatry, 155(1), 54-61.]])] ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             | 
 +^ Valproic acid                           | • Valproic acid should not be used for agitation and aggression in AD.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3980908/​|Herrmann,​ N., Lanctôt, K. L., & Hogan, D. B. (2013). Pharmacological recommendations for the symptomatic treatment of dementia: the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 2012. Alzheimer'​s research & therapy, 5(1), S5.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​21810649/​|Tariot,​ P. N., Schneider, L. S., Cummings, J., Thomas, R. G., Raman, R., Jakimovich, L. J., ... & Alzheimer'​s Disease Cooperative Study Group. (2011). Chronic divalproex sodium to attenuate agitation and clinical progression of Alzheimer disease. Archives of General Psychiatry, 68(8), 853-861.]])] ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                | 
 +^ Benzodiazepines ​                        | Evidence for the efficacy of benzodiazepines in BPSD is poor. There are few studies that show its efficacy. Benzodiazepines are associated with sedation, dizziness, falls, worsening cognition, respiratory depression, dependency and paradoxical disinhibition in the elderly.[([[https://​www.ncbi.nlm.nih.gov/​labs/​pmc/​articles/​PMC5518961/​|Kales,​ H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. Bmj, 350.]])] ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | 
 +^ Stimulants ​                             | Methylphenidate can be effective in treating apathy in Alzheimer'​s disease, with the individuals deriving the most benefit if they are not anxious or agitated, younger, already prescribed a ACHEI, have optimal (73-80 mm Hg) diastolic blood pressure, or having more impaired function.[([[https://​pubmed.ncbi.nlm.nih.gov/​37385898/​|Lanctôt,​ K. L., Rivet, L., Tumati, S., Perin, J., Sankhe, K., Vieira, D., ... & Herrmann, N. (2023). Heterogeneity of response to methylphenidate in apathetic patients in the ADMET 2 Trial. The American Journal of Geriatric Psychiatry.]])] ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                | 
 +^ Other                                   | Other potential medications with some positive results include dextromethorphan-quinidine,​[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​26393847|Cummings,​ J. L., Lyketsos, C. G., Peskind, E. R., Porsteinsson,​ A. P., Mintzer, J. E., Scharre, D. W., ... & Shin, P. (2015). Effect of dextromethorphan-quinidine on agitation in patients with Alzheimer disease dementia: a randomized clinical trial. Jama, 314(12), 1242-1254.]])] and prazosin.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2842091/​|Wang,​ L. Y., Shofer, J. B., Rohde, K., Hart, K. L., Hoff, D. J., McFall, Y. H., ... & Peskind, E. R. (2009). Prazosin for the treatment of behavioral symptoms in patients with Alzheimer disease with agitation and aggression. The American Journal of Geriatric Psychiatry, 17(9), 744-751.]])] ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | 
 +^ Nabilone ​                               | Nabilone may be effective in reducing agitation, but caution is warranted as it may cause excessive sedation and cognitive impairment.[([[https://​pubmed.ncbi.nlm.nih.gov/​31182351/​|Herrmann,​ N., Ruthirakuhan,​ M., Gallagher, D., Verhoeff, N. P. L., Kiss, A., Black, S. E., & Lanctôt, K. L. (2019). Randomized placebo-controlled trial of nabilone for agitation in Alzheimer'​s disease. The American Journal of Geriatric Psychiatry, 27(11), 1161-1173.]])] ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      | 
 +</​mobiletable>​ 
 +</​panel>​
  
-== Atypical antipsychotics ​== +==== Antipsychotics ==== 
-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.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​18494535|Salzman,​ C., Jeste, D., Meyer, R. E., Cohen-Mansfield,​ J., Cummings, J., Grossberg, G., ... & Pollock, B. (2008). Elderly patients with dementia-related symptoms of severe agitation and aggression: consensus statement on treatment options, clinical trials methodology,​ and policy. The Journal of clinical psychiatry, 69(6), 889.]])] There are clear risks for increased all-cause mortality and stroke risk when antipsychotics are used, and the benefits must outweigh the risks.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16234500|Schneider,​ L. S., Dagerman, K. S., & Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. Jama, 294(15), 1934-1943.]])] 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.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​22193526|Kales,​ H. C., Kim, H. M., Zivin, K., Valenstein, M., Seyfried, L. S., Chiang, C., ... & Blow, F. C. (2012). Risk of mortality among individual antipsychotics in patients with dementia. American Journal of Psychiatry, 169(1), 71-79.]])] Antipsychotics also can bring on other side effects, including falls, metabolic side effects, hypotension,​ cognitive impairment, and pneumonia+  * [[meds:​antipsychotics:​second-gen-atypical:​1-risperidone|Risperidone]] and [[meds:​antipsychotics:​second-gen-atypical:​3-brexpiprazole|brexpiprazole]] are the two antipsychotic medications Health Canada approval for severe agitation, aggression, and psychosis/​or associated with BPSD, where there is risk of harm to the patient and/or others. 
- +    * Olanzapine and aripiprazole also have evidence but are off-label. 
-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.[([[https://​www.nzma.org.nz/​journal/​read-the-journal/​all-issues/​2010-2019/​2011/​vol-124-no-1336/​article-cheung|Cheung,​ G., & Stapelberg, J. (2011). Quetiapine for the treatment of behavioural and psychological symptoms of dementia (BPSD): a meta-analysis of randomised placebo-controlled trials. The New Zealand Medical Journal (Online), 124(1336).]])] It can be tried in patients with parkinsonism ([[geri:​dementia:​lewy-body|LBD]] or [[geri:​parkinsons|]])+  * Quetiapine has recently had conflicting evidence, as recent meta-analyses have found a strong placebo effect.[([[https://​www.nzma.org.nz/​journal/​read-the-journal/​all-issues/​2010-2019/​2011/​vol-124-no-1336/​article-cheung|Cheung,​ G., & Stapelberg, J. (2011). Quetiapine for the treatment of behavioural and psychological symptoms of dementia (BPSD): a meta-analysis of randomised placebo-controlled trials. The New Zealand Medical Journal (Online), 124(1336).]])] 
 +  * Quetiapine and clozapine are they only antipsychotics that can be used in patients with parkinsonism ([[geri:​dementia:​lewy-body|DLB]] or [[geri:​parkinsons|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.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​18494535|Salzman,​ C., Jeste, D., Meyer, R. E., Cohen-Mansfield,​ J., Cummings, J., Grossberg, G., ... & Pollock, B. (2008). Elderly patients with dementia-related symptoms of severe agitation and aggression: consensus statement on treatment options, clinical trials methodology,​ and policy. The Journal of clinical psychiatry, 69(6), 889.]])] 
 +  * There are clear risks for increased all-cause mortality and stroke risk when antipsychotics are used, and the benefits must outweigh the risks.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16234500|Schneider,​ L. S., Dagerman, K. S., & Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. Jama, 294(15), 1934-1943.]])] 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.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​22193526|Kales,​ H. C., Kim, H. M., Zivin, K., Valenstein, M., Seyfried, L. S., Chiang, C., ... & Blow, F. C. (2012). Risk of mortality among individual antipsychotics in patients with dementia. American Journal of Psychiatry, 169(1), 71-79.]])] Antipsychotics also can bring on other side effects, including falls, metabolic side effects, hypotension,​ cognitive impairment, and pneumonia.
  
 <panel type="​info"​ title="​Antipsychotic Dosing"​ no-body="​true"​ footer="​*Quetiapine has conflicting evidence. It can be tried in patients with Parkinsonism,​ Lewy body dementia, or Parkinson'​s">​ <panel type="​info"​ title="​Antipsychotic Dosing"​ no-body="​true"​ footer="​*Quetiapine has conflicting evidence. It can be tried in patients with Parkinsonism,​ Lewy body dementia, or Parkinson'​s">​
-!^Antipsychotic ​ ^ Starting dose (mg)  ^ Frequency ​  ^ Titrate by (mg)  ^ Maximum daily dose (mg)  ^ Notable side effects ​                                                                                            ​+<​mobiletable 1> 
-| Risperidone ​   | 0.25                | daily/​BID ​  | 0.25             | 2                        | EPS, gait disturbance,​ infection risk (UTI/URTI), peripheral edema, orthostatic hypotension,​ metabolic syndrome ​ | +^ Antipsychotic ​                                                             ^ Starting dose (mg)  ^ Frequency ​  ^ Titrate by (mg)  ^ Maximum daily dose (mg)  ^ Notable side effects ​                                                                                                                                                                   
-| Olanzapine ​    ​| 1.25                | HS/​BID ​     | 1.25-2.5 ​        ​| ​7.5                        ​| EPS, gait disturbance,​ infection risk (UTI/URTI), peripheral edema, metabolic syndrome ​                          | +^ [[meds:​antipsychotics:​second-gen-atypical:​1-risperidone|Risperidone]]      ​| 0.25                | daily/​BID ​  | 0.25             | 2                        ​| [[meds:​antipsychotics:​eps|EPS]], gait disturbance,​ infection risk (UTI/URTI), peripheral edema, orthostatic hypotension, ​[[meds:​antipsychotics:​metabolic-syndrome|metabolic syndrome]] ​ | 
-| Loxapine ​      ​| 2.5                 | BID/​TID ​    | 2.5-5            | 25                       | EPS                                                                                                              +^ [[meds:​antipsychotics:​second-gen-atypical:​3-olanzapine|Olanzapine]]        ​| 1.25                | HS/​BID ​     | 1.25-2.5 ​        ​| ​10                       | [[meds:​antipsychotics:​eps|EPS]], gait disturbance,​ infection risk (UTI/URTI), peripheral edema, ​[[meds:​antipsychotics:​metabolic-syndrome|metabolic syndrome]] ​                          | 
-| Haloperidol ​   | 0.25                | daily/​BID ​  | 0.25-0.5 ​        | 2                        | EPS                                                                                                              +^ [[meds:​antipsychotics:​first-gen-typical:​3-loxapine|Loxapine]]              ​| 2.5                 | BID/​TID ​    | 2.5-5            | 25                       | [[meds:​antipsychotics:​eps|EPS]]                                                                                                                                                         
-| Aripiprazole ​  ​| 0.5                 | daily       | 0.5-1            | 10                     ​Insomnia, akathisia ​                                                                                             +^ [[meds:​antipsychotics:​first-gen-typical:​1-haloperidol|Haloperidol]]        ​| 0.25                | daily/​BID ​  | 0.25-0.5 ​        | 2                        ​| [[meds:​antipsychotics:​eps|EPS]]                                                                                                                                                         
-| Quetiapine* ​    ​| 12.5                | BID/​TID/​HS ​ | 12.5-25 ​         | 150                      | Orthostatic hypotension,​ sedation, QTc prolongation,​ agitation, insomnia ​                                        ​+^ [[meds:​antipsychotics:​second-gen-atypical:​3-aripiprazole|Aripiprazole]]    ​| 0.5                 | daily       | 0.5-1            | 10                       ​[[meds:​antipsychotics:​eps#​akathisia|Akathisia]]insomnia ​                                                                                                                              | 
-</​panel>​+^ [[meds:​antipsychotics:​second-gen-atypical:​3-brexpiprazole|Brexpiprazole]] ​ | 0.5                 | daily       | 0.5-1            | 3                        | [[meds:​antipsychotics:​eps#​akathisia|Akathisia]],​ insomnia ​                                                                                                                              
 +^ [[meds:​antipsychotics:​second-gen-atypical:​6-quetiapine|Quetiapine]]      ​| 12.5                | BID/​TID/​HS ​ | 12.5-25 ​         | 150                      | Orthostatic hypotension,​ sedation, ​[[meds:qtc|QTc prolongation]], agitation, insomnia ​                                                                                                  ​
 +</​mobiletable>​</​panel>​
  
-<callout type="​danger"​ title="​Typical Antipsychotics Are Contraindicated in Lewy Body Dementia"​ icon="​true">​A severe sensitivity reaction occurs in an estimated 25-50% of [[geri:​dementia:​lewy-body|]] patients administered typical antipsychotic drugs (especially haloperidol) in the usual dose range.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3913181/​|Boot,​ B. P., McDade, E. M., McGinnis, S. M., & Boeve, B. F. (2013). Treatment of dementia with Lewy bodies. Current treatment options in neurology, 15(6), 738-764.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​11815682|Marsh,​ L., Lyketsos, C., & Reich, S. G. (2001). Olanzapine for the treatment of psychosis in patients with Parkinson’s disease and dementia. Psychosomatics,​ 42(6), 477-481.]])][([[https://​neuro.psychiatryonline.org/​doi/​full/​10.1176/​jnp.10.4.473|Friedman,​ J. H., Ott, B. R., & Workman Jr, R. H. (1998). Should risperidone be used in Parkinson'​s disease?/​Reply. The Journal of neuropsychiatry and clinical neurosciences,​ 10(4), 473.]])] This results in cognitive impairment, sedation, increased/​irreversible acute onset of parkinsonism,​ or symptoms resembling [[meds:​antipsychotics:​nms-neuroleptic-malignant-syndrome|neuroleptic malignant syndrome]]. If an antipsychotic must be used, then low potency atypical antipsychotics like clozapine or quetiapine should be used.[([[https://​www.lbda.org/​go/​er|Lewy Body Dementia Association:​ Emergency Room Treatment of Psychosis]])]+<callout type="​danger"​ title="​Typical ​and High Potency ​Antipsychotics Are Contraindicated in Lewy Body Dementia ​and Parkinson'​s" icon="​true">​A severe sensitivity reaction occurs in an estimated 25-50% of [[geri:​dementia:​lewy-body|]] patients administered typical antipsychotic drugs (especially haloperidol) in the usual dose range.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3913181/​|Boot,​ B. P., McDade, E. M., McGinnis, S. M., & Boeve, B. F. (2013). Treatment of dementia with Lewy bodies. Current treatment options in neurology, 15(6), 738-764.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​11815682|Marsh,​ L., Lyketsos, C., & Reich, S. G. (2001). Olanzapine for the treatment of psychosis in patients with Parkinson’s disease and dementia. Psychosomatics,​ 42(6), 477-481.]])][([[https://​neuro.psychiatryonline.org/​doi/​full/​10.1176/​jnp.10.4.473|Friedman,​ J. H., Ott, B. R., & Workman Jr, R. H. (1998). Should risperidone be used in Parkinson'​s disease?/​Reply. The Journal of neuropsychiatry and clinical neurosciences,​ 10(4), 473.]])] This results in cognitive impairment, sedation, increased/​irreversible acute onset of parkinsonism,​ or symptoms resembling [[meds:​antipsychotics:​nms-neuroleptic-malignant-syndrome|neuroleptic malignant syndrome]]. If an antipsychotic must be used, then low potency atypical antipsychotics like clozapine or quetiapine should be used.[([[https://​www.lbda.org/​go/​er|Lewy Body Dementia Association:​ Emergency Room Treatment of Psychosis]])]
  
 </​callout>​ </​callout>​
  
-== Deprescribing ​== +==== Inappropriate Sexual Behaviour (ISB) ==== 
-  * [[http://www.cfp.ca/content/64/1/17?etoc|Bjerre, LM., Farrell, B., Hogel, M., Graham, L., Lemay, G., McCarthy, L., ... & Welch, V. (2018). Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomniaEvidence-based clinical practice guideline. Canadian Family Physician, 64(1), 17-27.]]+<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​See also: **[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596201/|Joller Pet alApproach to inappropriate sexual behaviour in people with dementiaCan Fam Physician2013;59(3):255-260. 
 +]]**</​alert>​
  
-== Acetylcholinesterase Inhibitors == +Inappropriate sexual behavior (ISB) can be an extremely disruptive form of BPSD, placing other individuals at riskand cause distress for caregiversNo randomized control trials have investigated ​the use of treatment of ISBbut several different classes have been used.
-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.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3980908/​|HerrmannN.Lanctôt, KL., & Hogan, D. B. (2013). Pharmacological recommendations for the symptomatic ​treatment of dementia: the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 2012. Alzheimer'​s research & therapy5(1), S5.]])] Many patients may already ​been on these medications as part of their disease treatment.+
  
-There is good first line evidence for the use of acetylcholinesterase inhibitors in behavioural symptoms (especially hallucinations and agitation) related to [[geri:​dementia:​lewy-body|]], in particular, ​ [[meds:dementia:​donepezil|donepezil]]  +<WRAP group> 
- and [[meds:​dementia:​rivastigmine|rivastigmine]].[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4772820/​|MatsunagaS., Kishi, T., Yasue, I., & Iwata, N. (2016). ​Cholinesterase inhibitors for Lewy body disorders: a meta-analysisInternational Journal of Neuropsychopharmacology19(2).]])] It may also be helpful in managing symptoms ​of depression, anxiety, and apathy.+<WRAP half column>​ 
 +<panel type="​info"​ title="​Non-pharmacological"​ subtitle="​Adapted fromDe GiorgiRet al. (2016). ​Treatment of inappropriate sexual behavior in dementiaCurrent treatment options in neurology18(9), 41." no-body="​true"​ footer="">​ 
 +<​mobiletable 1> 
 +^ 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                                                                                      | 
 +</​mobiletable>​ 
 +</​panel>​
  
-== Memantine == +</​WRAP>​ 
-<callout ​type="success">​{{fa>​arrow-circle-right?​color=green}} See main article: **[[meds:dementia:memantine|]]**</callout>+<WRAP half column>​ 
 +<​panel ​type="info" ​title="​Pharmacological (Psychotropics)"​ subtitle="​Adapted fromDe Giorgi, R. et al. (2016). Treatment of inappropriate sexual behavior in dementia. Current treatment options in neurology, 18(9), 41." no-body="​true"​ footer="">​ 
 +<​mobiletable 1> 
 +^ 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 ​                                                                                                                          | 
 +</​mobiletable>​ 
 +</​panel>​ 
 +</​WRAP>​ 
 +</WRAP>
  
-There is somewhat limited evidence for memantine, and prospective RCTs have been negative. +<panel type="​info"​ title="​Pharmacological (Hormonal and Antiandrogen)"​ subtitle="​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 dementiaCan Fam Physician. 2013;​59(3):​255-260."​ no-body="​true"​ footer="">​ 
- +<​mobiletable 1> 
-== Anticonvulsants ​=+^ Hormonal and antiandrogen agents ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   ^ Mechanism of action ​                                                                                                                                                                                                                ^ Dosing ​                                                                                             ^ Potential adverse effects ​                                                                                                                                                     ^ 
-Carbamazepine been shown to have some utility ​in treating BPSD.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/9433339|Tariot, P. N., ErbR., Podgorski, C. A., CoxC., Patel, S., JakimovichL., & IrvineC. (1998). Efficacy and tolerability ​of carbamazepine ​for agitation and aggression ​in dementia. ​American ​Journal of Psychiatry155(1), 54-61.]])] There is no evidence for [[meds:mood-stabilizers-anticonvulsants:​1-valproic-divalproex|valproic acid]]. +^ Medroxyprogesterone (MPA)[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3596201/|Joller, P., Gupta, ​N., SeitzD. P., Frank, C., GibsonM., & Gill, S. S. (2013). Approach to inappropriate sexual behaviour in people with dementia. Canadian Family Physician59(3)255-260.]])][([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC1413960/​|Light,​ S. A., & HolroydS. (2006). The use of medroxyprogesterone acetate ​for the treatment of sexually inappropriate behaviour ​in patients with dementia. Journal of psychiatry & neuroscience31(2), 132.]])]  | 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)[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3596201/​|Joller, P., Gupta, N., Seitz, D. P., Frank, C., Gibson, M., & Gill, S. S. (2013). Approach to inappropriate sexual behaviour in people ​with dementia. Canadian Family Physician, 59(3), 255-260.]])] ​                                                                                                                                                                                                                                                                            | Synthetic progestin and antiandrogen that blocks androgen receptors ​                                                                                                                                                                | CPA 10 to 50mg PO daily                                                                             | Gynecomastiagalactorrhea,​ worsening diabetes control, depression, osteoporosis,​ adrenal insufficiency on withdrawal, hepatotoxicity (liver enzymes should be checked first) ​ | 
-== Other == +^ Finasteride[([[https://​pubmed.ncbi.nlm.nih.gov/​20121967/|Na, H. R., Lee, J. W., ParkSM., KoSB., KimS., & Cho, ST. (2009). Inappropriate sexual behaviors in patients with vascular dementia: possible response to finasteride. Journal of the American Geriatrics Society57(11)2161-2162.]])]                                                                                                                                                                                                                                                       | 5α-reductase inhibitor that blocks conversion of testosterone to dihydrotesterone ​                                                                                                                                                  | Finasteride 5mg PO daily                                                                            | Gynecomastia,​ testicular pain, depression ​                                                                                                                                     | 
-Other potential medications ​with some positive results include dextromethorphan-quinidine,​[([[https://​www.ncbi.nlm.nih.gov/​pubmed/26393847|Cummings, J. L., LyketsosCG., PeskindER., PorsteinssonAP., MintzerJE., Scharre, D. W., ..ShinP. (2015). Effect of dextromethorphan-quinidine on agitation ​in patients ​with Alzheimer disease ​dementia: a randomized clinical trialJama314(12), 1242-1254.]])] and prazosin.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2842091/|WangLY., ShoferJB., RohdeK., HartKL., HoffDJ., McFallYH., ... & PeskindER. (2009). Prazosin for the treatment of behavioral symptoms ​in patients ​with Alzheimer disease with agitation and aggressionThe American Journal of Geriatric Psychiatry17(9), 744-751.]])]+^ Estrogen[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3596201/​|JollerP., Gupta, N., Seitz, D. P., Frank, C., Gibson, M.GillS. S. (2013). Approach to inappropriate sexual behaviour ​in people ​with dementia. ​Canadian Family Physician59(3), 255-260.]])]                                                                                                                                                                                                                                                                                              | 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[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3596201/|JollerP., Gupta, N., SeitzDP., FrankC., GibsonM., & Gill, SS. (2013). Approach to inappropriate sexual behaviour in people with dementia. Canadian Family Physician59(3)255-260.]])]                                                                                                                                                                                                                                                                                            | Leuprolide is a gonadotropin-releasing hormone (GnRH) analogIt suppress testosterone\\ production by stimulating the secretion of pituitary LH and FSHwith subsequent increase in estrogen levels and decrease of testosterone ​ | Leuprolide acetate 7.5 mg IM qmonthly ​                                                              | Weight gainbone pain, osteoporosis,​ mood changes, pituitary apoplexy (rare) ​                                                                                                 | 
 +^ Spironolactone[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3596201/​|JollerP., Gupta, N., Seitz, DP., Frank, C., Gibson, M., GillSS. (2013). Approach to inappropriate sexual behaviour ​in people ​with dementiaCanadian Family Physician59(3), 255-260.]])]                                                                                                                                                                                                                                                                                        | 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 ​                                                                             | 
 +</​mobiletable>​ 
 +</​panel>​
  
 +==== Deprescribing ====
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​
 +See also:
 +  * **[[http://​www.cfp.ca/​content/​64/​1/​17?​etoc|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.]]**
 +  * **[[https://​alz-journals.onlinelibrary.wiley.com/​doi/​full/​10.1002/​trc2.12099|Herrmann,​ N. et al. (2022). CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia. Alzheimer'​s & Dementia: Translational Research & Clinical Interventions,​ 8(1), e12099.]]**
 +</​alert>​
  
 +  * One should consider a trial of tapering and withdrawing pharmacotherapy for BPSD after 3 months of behavioural stability. This is because the patient may no longer require these same medications due to the progression of the dementia.
 +  * Antipsychotic withdrawal studies also show reduced mortality risk with antipsychotic discontinuation.[([[https://​pubmed.ncbi.nlm.nih.gov/​19138567/​|Ballard,​ C., Hanney, M. L., Theodoulou, M., Douglas, S., McShane, R., Kossakowski,​ K., Gill, R., Juszczak, E., Yu, L. M., Jacoby, R., & DART-AD investigators (2009). The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. The Lancet. Neurology, 8(2), 151–157. https://​doi.org/​10.1016/​S1474-4422(08)70295-3]])]
  
 ==== ECT ==== ==== ECT ====
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See main article: **[[brain-stimulation:​ect|]]**</​alert>​
   * [[https://​www.ncbi.nlm.nih.gov/​pubmed/​28095946|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.]]   * [[https://​www.ncbi.nlm.nih.gov/​pubmed/​28095946|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.]]
  
 +===== Guidelines =====
 +{{page>​teaching:​clinical-practice-guidelines-cpg#​bpsd&​nouser&​noheader&​nodate&​nofooter}}
  
 ===== Resources ===== ===== Resources =====
 <WRAP group> <WRAP group>
-<​WRAP ​third column>+<​WRAP ​quarter ​column>
 == For Providers == == For Providers ==
-  * [[http://www.bcbpsd.ca|BC BPSD Algorithm App]]+  * [[https://​bcbpsd.ca/|BC BPSD Algorithm App]]
   * [[https://​www.bmj.com/​rapid-response/​2011/​11/​03/​rather-analgesia-focus-bowels-bladder-beverage-and-bottom|Rather than analgesia focus on "​Bowels,​ Bladder, Beverage and Bottom"​]]   * [[https://​www.bmj.com/​rapid-response/​2011/​11/​03/​rather-analgesia-focus-bowels-bladder-beverage-and-bottom|Rather than analgesia focus on "​Bowels,​ Bladder, Beverage and Bottom"​]]
  
 </​WRAP>​ </​WRAP>​
-<​WRAP ​third column>+ 
 +<​WRAP ​quarter ​column>
 == Guidelines == == Guidelines ==
   * [[https://​www.bcmj.org/​articles/​therapeutic-approaches-management-behavioral-and-psychological-symptoms-dementia-elderly|Drouillard,​ N., Mithani, A., & Chan, P. K. (2013). Therapeutic approaches in the management of behavioral and psychological symptoms of dementia in the elderly. BCMJ, 55(2), 90-95.]]   * [[https://​www.bcmj.org/​articles/​therapeutic-approaches-management-behavioral-and-psychological-symptoms-dementia-elderly|Drouillard,​ N., Mithani, A., & Chan, P. K. (2013). Therapeutic approaches in the management of behavioral and psychological symptoms of dementia in the elderly. BCMJ, 55(2), 90-95.]]
   *  [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4707529/​|Kales,​ H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. bmj, 350(7), h369.]]   *  [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4707529/​|Kales,​ H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. bmj, 350(7), h369.]]
 </​WRAP>​ </​WRAP>​
-<​WRAP ​third column>+ 
 +<​WRAP ​quarter ​column>
 == For Patients == == For Patients ==
   * {{ ::​mas_20questionsthathelpexplainwhypeoplewithdementiagetagitated.pdf |20 Questions that Help Explain Dementia Aggression (PDF)}}   * {{ ::​mas_20questionsthathelpexplainwhypeoplewithdementiagetagitated.pdf |20 Questions that Help Explain Dementia Aggression (PDF)}}
 </​WRAP>​ </​WRAP>​
 +
 +<WRAP quarter column>
 +== Articles ==
 +  * [[https://​www.nytimes.com/​2021/​09/​11/​health/​nursing-homes-schizophrenia-antipsychotics.html|NYT:​ Phony Diagnoses Hide High Rates of Drugging at Nursing Homes]]
 +</​WRAP>​
 +
 </​WRAP>​ </​WRAP>​