Dementia Part 2: BPSD Flashcards
What is BPSD?
Behavioral and psychological symptoms
- spectrum of non-cognitive and non-neurological symptoms of dementia such as agitation, aggression, psychosis, depression, and apathy
- often an attempt to communicate
- at least 80% of dementia pts experience BPSD
What are typically the first symptoms of BPSD?
What about later stages?
First symptoms: depression, anxiety
Later stages: agitation, aggression
Why is treatment of BPSD important?
BPSD can be extremely stressful for the pt and his/her caregiver and family
APpropriate tx can improve QoL of pt and family
[Factors that may contribute to BPSD]
Medical
- Depression
- Anxiety
- Delirium - could be due to infection, metabolic disturbances - hypothyroidism, medicine toxicity, substance withdrawal, dehydration
- Untreated pain
- Infection esp UTI or pneumonia
- Dehydration or hyponatremia
- Constipation or urinary retention
- Fatigue
- Hearing/Visual impairment
Impt to identify and treat
[Factors that may contribute to BPSD]
Pharmacological
- Medicines with anticholinergic action (e.g., Amitriptyline, Oxybutynin)
- Anticonvulsants (e.g., CBZ, PHT)
- Systemic corticosteroids esp at high doses, try to shift earlier in the day
- Medicines with sedative action (e.g., opioids, BZDs, Zopiclone, antihistamines), take at night to avoid sleeping too much in the day
- Anti-parkinsonian medicines
[Factors that may contribute to BPSD]
Environmental or Social
- Unfamiliar environment
- Separation from family
- Noise
- Crowding
- Loneliness
- Difficult rsp with caregiver/family
- Lack of privacy
- Difficulty finding facilities
- Difficulty accessing outdoors
- Lack of space to move around
- Perceived lack of security
- Glare from sunlight or artificial lighting or poor lighting
- Under or overstimulation
- Withdrawal from alcohol or drug
Non-pharmacological treatment approach for BPSD
- what treatment approach should be taken?
Patient-centered approach
- Understand pt background
- Understand the relationship b/w pt and carer
- Understand the stresses that the condition is placing on both the pt and the carer
Pharmacological treatment approach for BPSD
- Role and evidence
Limited role in management of BPSD
- Always used in combination with non-pharmacological interventions
- Prescribe only for target symptoms or behaviors for which there is evidence of effectiveness
- Only considered once potentially reversible causes have been excluded and non-pharmacological interventions have been trialed
Exception: there is immediate risk to the pt, or pt is very severely distressed (then we may use a pharmacologic to calm pt down first)
Pharmacological treatment approach for BPSD
- General guide for how to use
- Initiate as a trial, not indefinitely
- Review response to treatment, dose, and adverse effects at least every 3 months
- Routinely withdrawn, slowly, after 3 months of improved symptoms unless symptoms were severe or due to a comorbid psychiatric disorder (e.g., bipolar depression)
- Restart at the lowest effective dose If symptoms return following a withdrawal; schedule further trial withdrawal in 3-6 months
BPSD Target Behavior: Agitation and Aggression
- Describe presentation
Can be verbal, e.g., complaining, angry statements, threats
Or physical, e.g., resistiveness to carers, restlessness, spitting, hitting out
BPSD Target Behavior: Agitation and Aggression
- Non-pharmacologic
Rule out/Manage: underlying depression, unmet needs, boredom, discomfort, perceived threat, violation of personal space etc.
Make environmental or management modifications:
- Calming and positive experience interventions such as music or touch therapy, sensory stimulation
- E.g., hand massage, mechanical pet, twiddle muff
- music, exercise, aroma therapy
BPSD Target Behavior: Agitation and Aggression
- Pharmacologic
- Antipsychotics
- SSRI: Citalopram (shown to reduce agitation in pt with AD)
BPSD Target Behavior: Depression
- Describe presentation
- More prevalent in early stages
- May present as sadness, tearfulness, pessimistic thoughts, withdrawal, inactivity, fatigue
BPSD Target Behavior: Depression
- Non-pharmacologic
- Exercise
- Social engagement
- Cognitive behavioural therapy (CBT)
Note that severe depression may require input from clinician with experience
BPSD Target Behavior: Depression
- Pharmacologic
SSRI
BPSD Target Behavior: Anxiety
- Describe presentation
In later stages, anxiety may be an exaggerated response to separation from family, reduced capacity to make sense of the environment
BPSD Target Behavior: Anxiety
- Non-pharmacologic
Identify and eliminate triggers, rather than symptom control
Assess if sensory overstimulation may be contributing to anxiety
Maintain structure and routine and reduce ned for stressful decision-making
Music and CBT have shown benefit
BPSD Target Behavior: Anxiety
- Pharmacologic
SSRI
When might CBT be considered?
https://www.alzheimers.org.uk/Care-and-cure-magazine/summer-18/cognitive-behavioural-therapy-cbt-dementia
CBT is only relevant if you have both dementia and anxiety or depression. If you do have this combination of difficulties, it is good to start as early as you can. In an ideal situation, people would be assessed at the time of diagnosis with dementia and introduced to CBT then, if it seems like it might be appropriate.
CBT is a language based therapy, and for people with dementia who struggle with language, CBT may be more challenging.
In general, greater levels of cognitive impairment may make it more difficult to engage with CBT, however, it may be possible to tailor CBT according to an individual’s level of functioning. One of the things that I have been working on is developing questionnaires that will help us to understand which type of CBT a particular individual living with dementia might be most able to engage with.
BPSD Target Behavior: Apathy
- Describe presentation
Mostly occur in pt with vascular, lewy body, frontotemporal dementia; less in AD
Present as lack of initiative/motivation, aimless, reduced emotional response
Distinguish from depression: absence of sadness and other psychological distress
BPSD Target Behavior: Apathy
- Non-pharmacologic
Provide enriched prompts and cues to overcome apathy and generate positive behavior
- Reading to the person and encouraging to ask questions
- Small group and individual activities (e.g., puzzules, games, sensory stories)
- Music
- Exercise
- Multi-sensory stimulation with touch, smell, sound
- Spending time with pets
BPSD Target Behavior: Psychotic symptoms
- Describe presentation
Delusions, Hallucinations
- In dementia, delusions are usually reflective of underlying memory loss or changes in perceptions (e.g., accusation of theft of personal items); associated with mania or schizophrenia
- Vivid visual hallucinations are common in Lewy body, less auditory hallucinations
BPSD Target Behavior: Psychotic symptoms
- Non-pharmacologic
Resolve any potential reversible causes of psychosis such as sensory/vision/hearing loss, overstimulation, delirium, initiation of new medicine or substance misuse
Confirm that the pt claims are not occurring - use visual aids/photographs
Distraction
BPSD Target Behavior: Psychotic symptoms
- Pharmacologic
- Antipsychotics
- SSRI: Citalopram may improve delusion symptoms
BPSD Target Behavior: Wandering
- Describe presentation
May be related to agitation
Present as circular pacing b/w two points, random or direct to a location without diversion
poses safety concerns
BPSD Target Behavior: Wandering
- Non-pharmacologic
Wandering can be improved by:
- exercise
- improve sleep
- improve mood
- improve general health
Consider how to make wandering safe:
- do not restrain/contain the pt as he/she may act out
- supervised walks
- secured space to roam
- GPS watch
Determine if there is a purpose to wandering
- e.g., trying to return home, looking for someone, escaping from perceived threat
BPSD Target Behavior: Nocturnal disruptions
- Describe presentation
Sleep disturbance can occur secondary to depression, anxiety, agitation, or pain; may cause other BPSD to be exacerbated at night (e.g., wandering at night)
More frequent in Lewy body dementia
Sundowning
- increased agitation in late afternoon
Sleep-wake reversal
- disrupted sleep cycle
BPSD Target Behavior: Nocturnal disruptions
- Non-pharmacological
Assess and exclude underlying causes:
- depression
- anxiety
- agitation
- untreated pain
- thirst/hunger
Non-pharm:
- restrict caffeine in the evening
- limit fluid intake before bedtime
- establish night-time routine (minimize light and noise, ensure adequate stimulating activities during the day)
- bright light therapy - helps to regulate circadian rhythm, helps with disorientation (confusion etc.)
What are the BPSD behaviors that occur more commonly with Lewy Body dementia?
- Apathy
- Psychotic symptoms: vivid visual hallucinations
- Nocturnal disturbances
Use of SSRIs
Indicated for depression and anxiety
Citalopram - shown to reduce agitation, improve delusions
Consider adverse effects:
- dose-dependent risk of increased QT PROLONGATION
- worsening cognition
Use of TCAs
Generally not used bc of anticholinergic effects that may further disrupt cognition
Use of antipsychotics
- Indication
Indicated only if aggression, agitation, or psychotic symptoms (hallucinations, delusions) are causing severe distress to the pt or if there is immediate risk of harm to the pt or others
Already indicated:
- Patient alr has pre-existing, co-morbid mental illness where antipsychotics are indicated
NOTE: Risperidone is NOT approved for dementia-related psychosis, only improved for aggression in dementia
Use of antipsychotics
- Effectiveness
- Moderate effective in managing BPSD
- Unlikely to benefit symptoms of wandering, calling out, social withdrawal, or inappropriate sexualized behavior in people with dementia
- Less likely effective for intermittent but challenging behaviors that are closely related to clear environmental triggers (e.g., aggression that only occurs during personal cares)
Use of antipsychotics
- Concerns with antipsychotics use
- Increase risk of stroke, cardiovascular events, and mortality in older patients with dementia
- Note that the most common causes of death in older people taking antipsychotic medicines appears to be pneumonia, stroke, and cardiac arrest
- Pneumonia may be due to sedative properties of antipsychotics, hence increasing the likelihood of aspiration
Use of antipsychotics
- Duration of use (NICE guideline)
- Lowest dose, shortest possible time
- Should be tried alongside non-pharmacological activities
- Assess at least every 6 weeks, stop if there is no improvement or if it is no longer needed
Use of antipsychotics
- Common SEs to look out for
- Feeling sleepy, less alert
- Headache
- Changes in appetite, weight gain
- Symptoms like Parkinson’s disease (slow movement, stiffness, freezing, tremor, increased saliva or drooling, loss of expression on face)
Use of antipsychotics
- Based no NICE guidelines, which antipsychotics can be used
Risperidone (up to 6 weeks), Haloperidol are licensed to treat BPSD in people with dementia
Other antipsychotics and Risperidone beyond 6 weeks are off-label use
What about other anxiolytics like BZDs such as diazepam or other sleep medications?
May consider if needed based on indication for BPSD target behavior
- E.g., BZD should not be used to sedate pt who are difficult to manage; however, can be used to calm aggressive patients who are affecting others
