File Name: behavioral and psychological symptoms of dementia and their management .zip
Celestino, Florindo Stella, Catherine V. Piersol, Orestes V. Behavioral and psychological symptoms of dementia BPSD are defined as a group of symptoms of disturbed perceptive thought content, mood, or behavior that include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, and wandering.
Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. Behavioral and psychological symptoms of dementia BPSD are not uncommon in patients with dementia and include noncognitive symptoms and behaviors such as agitation, anxiety, apathy, delusions, depression, and halluci nations.
BPSD is associated with worse outcomes for patients with dementia. Management is not standardized, but protocols generally involve the treatment of underlying symptoms followed by the use of nonpharmacological management techniques and evidence-based pharmacotherapy for refractory BPSD. Alzheimer disease and other dementias are a major and increasing global health challenge. In there were Behavioral and psychological symptoms of dementia BPSD is used to describe a group of diverse non-cognitive symptoms and behaviors that are frequently seen among individuals with dementia.
Antipsychotics are often over-used in this situation. Their use is associated with significant risks in people with dementia, and they are only effective for specific behaviours, such as psychosis and agitation. This is the third article in a series on cognitive impairment and dementia in older people. The final article in the series will focus on palliative care for people with dementia.
See side menu for other articles in the series. Although the evidence base for non-pharmacological treatments of BPSD is not strong, in part because person-centred treatment approaches are difficult to study, there are generally fewer risks associated with these interventions and they should always be considered first.
Non-pharmacological interventions should be tailored to the individual patient and the target behaviour s and the response monitored. Managing BPSD requires a targeted approach, i. A request for a home risk assessment may be necessary to assess any danger the patient may present to themselves or others. Table 1: Common presentations of frequently encountered BPSD and non-pharmacological management strategies The NPI can be completed by a family member or carer in less than five minutes.
The questions relate to behavioural changes that have occurred since the onset of dementia. The NPI provides a severity score three point scale and carer distress ratings five point score for each symptom and total severity and distress scores.
The total score is not useful if the BPSD is isolated to one subtype. Consider factors that may be causing or exacerbating the behaviour; Table 2 lists some common examples:. It is estimated that at least half of people with dementia regularly experience pain due to causes such as osteoarthritis and other musculoskeletal conditions, falls, pressure ulcers, infections, neuropathy, urinary retention, constipation, dental abscesses, cerumen ear wax or other co-morbidities.
Regularly enquire about pain with simple questions, e. Look for non-verbal indicators of pain such as body language, breathing patterns, facial expressions or negative vocalisation. The Abbey Pain Scale is an example of a useful tool for assessing potential pain in patients with dementia: www.
Non-pharmacological treatments and interventions should be trialled first for managing BPSD. Once a non-pharmacological intervention has been introduced, the patient should be monitored to determine the effect of the intervention. Specific behavioural interventions for BPSD will depend on the target behaviour that requires modification Table 1. In general, encourage people with dementia to participate in activities that they find enjoyable and meaningful and are appropriate to their level of function, e.
Age Concern provide an accredited visiting service where a younger person may visit an older person for approximately an hour each week: www. There is some evidence that structured interventions including music therapy, cognitive behavioural therapy and sensory therapy are beneficial for managing some BPSD including apathy, agitation, vocally disruptive behaviour, depression and anxiety.
Pharmacological interventions have a limited role in the management of BPSD as they are associated with a range of serious adverse effects in older people and the indications for which they are effective is relatively limited.
Selective serotonin reuptake inhibitors SSRIs are effective for the management of depression and anxiety in people with dementia that cannot be managed by non-pharmacological interventions alone.
Tricyclic antidepressants should generally not be prescribed to patients with dementia as the anticholinergic effects may further disrupt cognition.
Antipsychotics are only appropriate for patients with BPSD if aggression, agitation or psychotic symptoms are causing severe distress or an immediate risk of harm to the patient or others or if the patient has a pre-existing, co-morbid mental illness where antipsychotics are indicated.
Antipsychotic medicines are only modestly effective in managing BPSD, and the level of effectiveness varies between patients. Antipsychotics are unlikely to be beneficial for wandering, calling out, social withdrawal or inappropriate sexualised behaviour in people with dementia.
Even short courses of antipsychotics can cause significant adverse effects in people with dementia, e. Antipsychotics should be avoided in patients with Lewy body dementia or Parkinsons disease with dementia , as they can cause severe adverse reactions, particularly extrapyramidal symptoms. There is significant concern that antipsychotics may cause strokes, cardiovascular events and death for some older people, particularly those with dementia.
At this stage, there is insufficient evidence to state with certainty if some antipsychotics are safer than others for the management of patients with BPSD. In older patients, all antipsychotic medicines are associated with an increased risk of stroke, cardiovascular events and excess mortality over a relatively short time frame. For example, it has been estimated that for every 1, patients with dementia who take an antipsychotic for six to 12 weeks, 12 additional people will have a stroke eight other people will have a stroke whether they have taken the medicine or not.
The most common causes of death in older people taking antipsychotic medicines appears to be pneumonia, stroke and cardiac arrest. A visual tool demonstrating the increased stroke and mortality risk associated with the use of antipsychotics in people with dementia is provided by the National Institute for Health and Care Excellence NICE , available from: www. It is not possible to definitively recommend a single, safest and most effective antipsychotic medicine for BPSD.
Risperidone is usually trialled first as it has strong evidence of effectiveness for BPSD, including psychosis, agitation and aggression. There is moderate evidence that aripiprazole is effective for the treatment of aggression and agitation in people with BPSD, but not psychosis. There is currently insufficient evidence to support the use of the newer atypical antipsychotics, amisulpride and ziprasidone for the treatment of older patients with BPSD. Antipsychotic medicines for the management of BPSD should be initiated as a trial and should not be prescribed indefinitely; treatment should ideally not exceed three months.
Table 4: Recommended starting and maintenance doses for antipsychotic medicines in older people with dementia The adverse effects associated with antipsychotics are generally dose-related and the risk can be minimised by regularly reviewing treatment, reducing the dose where possible and withdrawing treatment once the target behaviour is well-controlled.
Close monitoring is required, especially in patients who are taking medicines with the potential for interactions with antipsychotics, including for: A tool for estimating the anticholinergic burden of medicines in patients aged over 65 years is available from: www.
Many patients with BPSD can be withdrawn from antipsychotics following three months of stable or improved behaviour. If the patient does not respond to pharmaceutical treatment, confirm with their carer that they have been adherent to treatment and consider if the dose could be optimised and if treatment has continued for an adequate length of time, e.
If a patient has been taking an antipsychotic long-term, e. The increased risk of stroke, cardiovascular events and death associated with antipsychotic medicines in older people, and particularly those with dementia, is a significant clinical concern. It is currently unclear whether this risk is a class effect of if the risk is higher with specific medicines. What is certain is that the use of any antipsychotic medicine in people with dementia requires a careful risk versus benefit assessment.
If it is decided that the patient is likely to benefit from an antipsychotic medicine, an appropriate consent process is essential, as is limiting the duration of pharmacological treatment to the minimum time period that is clinically necessary.
The purpose of this report is to provoke thought and discussion about how and why antipsychotic medicines are prescribed to older patients. The report includes national data, and practice points for reflection. View national report. Expert reviewers do not write the articles and are not responsible for the final content. We have now added the ability to add replies to a comment. Simply click the "Reply to comment" button and complete the form.
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Hello there! Remember me. Please login to save this article. Log in. Age-related cognitive decline: prevention and future planning. Recognising and managing early dementia. Managing the behavioural and psychological symptoms of dementia You are reading this.
Understanding the role of palliative care for people with advanced dementia. Symptom management in palliative dementia care. National report and CME activities.
Published: 17 April, Can be verbal, e. May be due to underlying depression, unmet needs, boredom, discomfort, perceived threat or violation of personal space. Make environmental or management modifications to resolve these issues. Non-specific calming and positive experience interventions may be beneficial such as music or touch therapy, e.
Presents as lack of initiative, motivation and drive, aimlessness and reduced emotional response. Reduced motivation can be a feature of depression, but a pure apathy syndrome can be distinguished from depression by the absence of sadness and other signs of psychological distress.
Reading to the person and encouraging them to ask questions, small group and individual activities, e. Music, exercise, multi-sensory stimulation with touch, smell and sound, and spending time with pets can also be effective. The key is to provide enriched prompts and cues to overcome the apathy and generate positive behaviour. May present as sadness, tearfulness, pessimistic thoughts, withdrawal, inactivity or fatigue. Recommend exercise, social connection and engaging activities.
Cognitive behavioural therapy CBT may be helpful in early stages. Severe depression requires input from a clinician with experience in managing patients with dementia.
We review non-pharmacological and pharmacological approaches to managing behavioral and psychological symptoms of dementia BPSD. We examine methods for assessment and evidence for interventions, focusing on recent findings and innovations. Finally, we recommend an algorithm for management of BPSD. Training of formal caregivers is the most effective intervention for BPSD; other non-pharmacological interventions are also beneficial. Antidepressants and antipsychotics remain a mainstay of pharmacological treatment for BPSD. The management of BPSD is highly individualized. Following thorough assessment, the initial step is addressing contributing medical problems.
Behavioral and psychological symptoms of dementia BPSD are implicated in a cycle of negative events including deterioration of family and professional relationships, as well as increased caregiver burden, institutionalization, and risk of death in individuals with Alzheimer dementia AD. While behavioral therapies are recommended as first-line treatments for BPSD, they may be less effective with a delayed onset of action, especially for patients with the most severe agitation. For these reasons, psychotropic medications, especially antipsychotics, are widely used to treat agitation and associated behavioral symptoms in AD. However, efficacy data for antipsychotic medications are inconsistent 3 and their use is associated with increased mortality, resulting in a US Food and Drug Administration FDA boxed warning. Yunusa and colleagues 7 examined what were reported in randomized clinical trials to be the most effective and safe antipsychotic medications for the treatment of the behavioral and psychological symptoms of dementia. This network meta-analysis of 17 randomized clinical trials, the majority of which were conducted in nursing homes, includes patients with AD and related agitation, with a mean age of
Behavioral and psychological symptoms of dementia BPSD are an integral part of dementia syndrome. They increase morbidity and burden, affect quality of life and impact cost of care. This review aims to study the features of BPSD, their assessment and management. Available literature suggests that BPSD can manifest in multiple ways; the common components are of behavioral, affective, psychotic and somatic in nature. There are specific rating scales for assessing BPSD; however, there is need for developing cross-culturally validated instruments. Nonpharmacological interventions are preferred as first line, which mainly include environmental modification, social interactions, minimizing effect of sensory deficits and behavioral interventions.
The core symptoms of different dementia subtypes are the behavioral and psychological symptoms of dementia BPSD and its neuropsychiatric symptoms NPS. BPSD treatment consists of non-pharmacological as well as pharmacological interventions, with non-pharmacological interactions being suggested as first-line treatment. Agitation, psychotic features, apathy, depression, and anxiety may not respond to acetylcholinesterase inhibitors or memantine in AD cases; therefore, antipsychotics, antidepressants, sedative drugs or anxiolytics, and antiepileptic drugs are typically prescribed. However, such management of BPSD can be complicated by hypersensitivity to antipsychotic drugs, as observed in DLB, and a lack of effective pro-cognitive treatment in the case of frontotemporal dementia.
Metrics details. The main aim of this study was to determine the association between Behavioral and Psychological Symptoms of Dementia BPSD and caregiver burden, and the mediating role of coping strategy and personality style of caregivers to patients with dementia PWD. This cross-sectional study was conducted among caregivers to PWD in home-based settings.
Antipsychotics are often over-used in this situation. Their use is associated with significant risks in people with dementia, and they are only effective for specific behaviours, such as psychosis and agitation. This is the third article in a series on cognitive impairment and dementia in older people.
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Thus, categorization of BPSD in clusters taking into account their natural course, prognosis and treatment response may be useful in the clinical.Creasnionenrahn 23.05.2021 at 12:09
Keywords: behavioral and psychological symptoms, dementia, neuropsychiatric symptoms, Alzheimer's disease assessment of BPSD and for evaluation of their treatment. CLINICAL Manual of Mental Disorders, 4th.Charlotte B. 23.05.2021 at 18:42
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