- Last edited on April 30, 2020
Behavioural and Psychological Symptoms of Dementia (BPSD)
Primer
Behavioural and Psychological Symptoms of Dementia (BPSD) will develop in more than 90% of individuals diagnosed with dementia.[1] Symptoms include delusions, hallucinations, aggression, screaming, restlessness, wandering, depression, and anxiety. Other symptoms include disinhibition, sexual behaviours, apathy, sleep disturbances, and compulsive or repetitive behaviours. BPSD results in impaired quality of life, increased cost of care, rapid cognitive decline, and massive caregiver burden.
Prevalence
BPSD is extremely common in the community (60%), and in nursing homes (80%). More than 90% of patients with dementia develop BPSD over 5 years, and the majority of cases have serious clinical implications.[2]
Symptoms
BPSD symptoms can be organized into 5 symptom clusters:
- Apathy (lack of initiative)
- Psychosis (delusions, hallucinations)
- Aggression/Agitation (verbal, physical)
- Hyperactivity (pacing, restlessness, disinhibition)
- Affective (dysphoria, elation irritability, anxiety)
Is It Really Agitation?
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 it. Agitation is inappropriate verbal, vocal, or motor activity that is not judged by an outside observer to result directly from apparent needs or confusion of the agitated individual.[3] This means you must always need to understand if there were environment triggers or behaviours behind the “agitation.”Pathophysiology
Theoretical models that explain the causes of BPSD include:
- Unmet Needs Model (i.e. - the patient is unable to express needs)
- Progressively Lowered Stress Threshold Model (i.e. - ability to deal with stress or stimuli is impaired)
- ABC Model (Antecedent-Behaviour-Consequence learning theory)
Differential Diagnosis
A broad differential diagnosis must be considered at all times:
BPSD Differential Diagnosis
Delirium | Look for acute changes and fluctuations, and do a thorough delirium work up if suspected. Infections such as UTIs can be frequent culprits. |
---|---|
Depression | Major depressive disorder can be difficult to identify in advanced dementia |
Pain | Pain is frequently underdiagnosed, one must be vigilant and look for verbal and non-verbal cues.[4] If pain is properly managed and treated, this can improve agitation, mood, apathy, appetite, and reduce nighttime behaviours.[5] 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[6] |
Medical Triggers | • Dehydration • Constipation • Urinary or chest infection • Dental pain/infection • Pain |
Environmental Triggers | Identify the presence of any enivronmental triggers, which can often worsen or exacerbate BPSD[7] • Excessive noise or stimulation • Lack of structure/routine • Inadequate lighting • Confusing surroundings • Excessive demands • Loneliness/boredom • Behaviour of others |
The 4 B's
Also think about identifying the “4 B's” of discomfort in older adults:[8]
- Bowels: when was the patient’s last bowel movement
- Bladder: when did they last urinate? Any urinary symptoms?
- Beverage: are they hungry or thirsty? Have they been offered preferred beverages or food?
- Bottom (to Top): a visual survey for obvious precipitants of distress and agitation
Management
Managing BPSD requires a thorough assessment, involving multiple sources of information, including a medical history, social history, personal history, and habits. Family and caregivers also need to be interviewed. There also needs to be an adequate physical exam, bloodwork, and urine cultures.
Antecedent, Behaviour, and Consequences (ABCs)
It can often be helpful to break down the BPSD into ABC (Antecedent, Behaviour, and Consequences) charting. This helps you identify if there are patterns to the behaviours, and allows the use of behavioural techniques to extinguish some behaviours, instead of medications. The key is to avoid positively reinforcing unwanted behaviours (e.g. - man screams and nurse soothes him, which leads to more screaming to seek soothing in the future) and encourage the reinforcement of alternate behaviours (e.g. - screaming man gets only attention when he is calm). The challenge with implementing these behavioural care plans is that all staff and caregivers have to be involved and follow the plan. Otherwise, intermittent reinforcement increases and worsens the behaviour.
Sample ABC Charting
Antecedent | Behaviour | Consequence | |
---|---|---|---|
April 20, 8:00 PM | Patient continuously asks to go to bathroom and calls for help | Pulls of undergarment and urinates on floor | Was told not to do this, brought to room, cleaned and changed |
April 23, 8:30 PM | Sitting at nursing station | Asks to go to bathroom repeatedly, begins yelling for help | RN engages patient, distracts and becomes quieter, until RN leaves, and the behaviour re-starts |
April 27, 8:20 PM | Sitting alone in corner | Calls out “help” repeatedly | Was asked what was wrong and staff spent some time with her until she calmed down, but then it started again |
In this example, the antecedent is the patient is in situations where she frequently calls out for help and staff are not present. In order to extinguish this behaviour, she should be given more attention when she is calm, to reinforce the alternate behaviour.
Dementia Observational System (DOS)
Dementia Observational System (DOS)
Name | Rater | Description | Download |
---|---|---|---|
Dementia Observational System (DOS) | Observer/Clinician | The Dementia Observational System (DOS) is a tool used to assess a person’s behaviour over a 24 hour cycle for up to 7 days to determine the occurrence, frequency, and duration of behaviours of concern. | Download |
Describe, Investigate, Create, Evaluate (DICE)
The DICE Approach (Describe, Investigate, Create, Evaluate) is a model used to evaluate, manage, and treat BPSD, and to minimize the reflexive use of medications such as antipsychotics.[9][10] The evidence for non-pharmacological approaches to BPSD is better than the evidence for antipsychotics, and exceedingly better than for other classes of medication.
The DICE Approach
Kales, et al. Assessment and management of behavioral and psychological symptoms of dementia. BMJ 350.7 (2015)Describe | Patient, behavior, environment, situation, target |
---|---|
Investigate | Medical problem, medications, caregiver causes, environment |
Create | Environment, behavioral, pharmacological interventions |
Evaluate | Effect, side-effects |
Treatment
Non-pharmacological
Non-pharmacological interventions are a cornerstone of managing BPSD, and must not be forgotten! This includes physical exercises and activity programs, music therapy, therapeutic touch, bright light therapy, and aromatherapy.[11] The challenges with interpreting the efficacy of non-pharmacological interventions is they are often small in sample size, have no control groups, and have inadequate randomization. Other times, the interventions may be effective, but not financially feasible. The bottom line is that non-pharmacological treatments work, but there is no “one-size fits all” solution.
Pharmacological
It is important that not all symptoms of BPSD respond to medications, and a comprehensive non-pharmacological approach must be taken!
Are the Symptoms Responsive to Medications?
Symptoms and Medication Response
Usually not responsive | Can be responsive |
---|---|
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 |
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
Antidepressants
Citalopram (best evidence), escitalopram, sertraline, and trazadone have comparable effects as antipsychotics, in reducing delusions, anxiety, and irritability/lability.[12] In the elderly, it is particularly important to monitor for hyponatremia, and sodium levels should be drawn within 4 weeks. Trazodone has inconclusive evidence,[13] though it is commonly used due to its sedating effects. There are some positive results in the use of trazodone for frontotemporal dementia.[14]
Atypical 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.[15] There are clear risks for increased all-cause mortality and stroke risk when antipsychotics are used, and the benefits must outweigh the risks.[16] There is a 2-3 times increase in relative risk of cerebrovascular adverse event, and 1.7 times increase in risk of death. Although these are only relative risk increases (i.e. - the absolute risk of death is in fact quite low), it is important to obtain consent to treatment. The risk of death is highest for haloperidol, and lowest for quetiapine.[17] Antipsychotics also can bring on other side effects, including falls, metabolic side effects, hypotension, cognitive impairment, and pneumonia.
Risperidone (only one that has Health Canada approval), olanzapine and aripiprazole have the most evidence for severe agitation, aggression and psychosis associated with BPSD, where there is risk of harm to the patient and/or others. Quetiapine has conflicting evidence, as recent meta-analyses have found a strong placebo effect.[18] It can be tried in patients with parkinsonism (LBD or Parkinson's Disease (PD)).
Antipsychotic Dosing
Antipsychotic | Starting dose (mg) | Frequency | Titrate by (mg) | Maximum daily dose (mg) | Notable side effects |
---|---|---|---|---|---|
Risperidone | 0.25 | daily/BID | 0.25 | 2 | EPS, gait disturbance, infection risk (UTI/URTI), peripheral edema, orthostatic hypotension, metabolic syndrome |
Olanzapine | 1.25 | HS/BID | 1.25-2.5 | 7.5 | EPS, gait disturbance, infection risk (UTI/URTI), peripheral edema, metabolic syndrome |
Loxapine | 2.5 | BID/TID | 2.5-5 | 25 | EPS |
Haloperidol | 0.25 | daily/BID | 0.25-0.5 | 2 | EPS |
Aripiprazole | 0.5 | daily | 0.5-1 | 10 | Insomnia, akathisia |
Quetiapine* | 12.5 | BID/TID/HS | 12.5-25 | 150 | Orthostatic hypotension, sedation, QTc prolongation, agitation, insomnia |
Typical Antipsychotics Are Contraindicated in Lewy Body Dementia
A severe sensitivity reaction occurs in an estimated 25-50% of Dementia with Lewy Bodies (DLB) patients administered typical antipsychotic drugs (especially haloperidol) in the usual dose range.[19][20][21] This results in cognitive impairment, sedation, increased/irreversible acute onset of parkinsonism, or symptoms resembling neuroleptic malignant syndrome. If an antipsychotic must be used, then low potency atypical antipsychotics like clozapine or quetiapine should be used.[22]Deprescribing
Acetylcholinesterase Inhibitors
There is currently insufficient evidence to recommend for or against the use of acetylcholinesterase inhbitors and/or memantine for the treatment of BPSD in Alzheimer's disease as a primary indication.[23] Many patients may already been on these medications as part of their disease treatment.
There is good first line evidence for the use of acetylcholinesterase inhibitors in behavioural symptoms (especially hallucinations and agitation) related to Dementia with Lewy Bodies (DLB), in particular, donepezil and rivastigmine.[24] It may also be helpful in managing symptoms of depression, anxiety, and apathy.
Memantine
There is somewhat limited evidence for memantine, and prospective RCTs have been negative.
Anticonvulsants
Carbamazepine been shown to have some utility in treating BPSD.[25] There is no evidence for valproic acid.
Other
Other potential medications with some positive results include dextromethorphan-quinidine,[26] and prazosin.[27]