Behavioural and Psychological Symptoms of Dementia (BPSD)

see also:

• dementia
• managing violence or the aggressive patient in the ED
• Assessment and Management of People with Behavioural and Psychological Symptoms of Dementia (BPSD): A Handbook for NSW Health Clinicians

• BPSD is a collection of observed behaviours and psychological symptoms that tend to occur together in a person with dementia
• BPSD typically presents in the later stages of dementia, with 60–90% of people with dementia presenting with at least one BPSD during the course of the disease
• frequency of BPSD increases with the severity of dementia.
• BPSD is associated with carer stress, increased duration of hospitalisation and greater likelihood of placement in a residential aged care facility
• BPSD includes:
  • verbal agitation - aggressive and non-aggressive
  • physical agitation - aggressive and non-aggressive
  • psychosis
  • apathy
  • depression
  • anxiety
  • inappropriate sexual behaviour
    • implied
    • non-aggressive
    • intrusive
    • aggressive

• any situation in which the physical safety of the person, carers and other patients is potentially seriously compromised is considered an emergency
• it is essential to consider the cause of the behaviour – such as:
  • delirium
  • unmet needs
  • pain
  • urinary retention
• use non-pharmacological actions to prevent the behaviour escalating:
  • prevent self-harm, such as keeping the person away from open windows, balconies, electric cords and other equipment
  • remove from the immediate environment others who may be at risk
  • move the person so that continuous direct observation is possible, or to a secure unit where available
  • involve family or other carers
  • consider one to one staffing
  • in the ED, physical restraint may be the safest option to prevent harm to the patient and others
  • remember that the person with dementia will be afraid and confused
• ensure that all staff are aware of local policies and procedures for responding to behavioural emergencies
• acute sedation may be considered only if essential to immediately reduce risks to the person, other patients and staff in the immediate environment
  • generally oral sedation should be tried first such as:
    • o lorazepam 0.5-1.25mg (max. 7.5mg/24hrs)
    • s/l olanzapine 2.5-5mg (max. 10mg/24hrs)
    • o risperidone 0.5-1mg (max. 4mg/24hrs)
  • if fails, and there is no evidence of delirium, consider im olanzapine 2.5mg (up to 7.5mg)
    • AVOID within 2hrs of parenteral benzodiazepines as risk of resp. depression

• PBS:
  • The only psychotropic medication that has a specific PBS indication for the treatment of BPSD is Risperidone.
  • Cholinesterase inhibitors (ChIs) are indicated for the cognitive symptoms of mild to moderate Alzheimer’s disease (MiniMental State Examination score 10+)
  • Memantine is indicated for the treatment of cognitive symptoms of severe Alzheimer’s disease (Mini Mental State Examination score 10–14), rather than BPSD per se.
    • memantine is effective in the treatment of irritability, agitation, aggression and psychosis over 3 to 6 months in Alzheimer's disease
    • may be a modest benefit for BPSD in Vascular Dementia but not in Dementia with Lewy Bodies.
• The use of antidepressants for depression and antipsychotics for delusions, associated with dementia are reasonable.
  • Citalopram, a SSRI, has been found to be effective in the treatment of aggression and agitation with comparable efficacy to risperidone
• There are three ChIs – donepezil, galantamine and rivastigmine – that are similar in efficacy.
  • Their main effects are in preventing emergent BPSD rather than treating existing BPSD.
  • they have a small benefit in BPSD especially for depression, dysphoria, anxiety, apathy and indifference
• Mx of psychosis symptoms of BPSD:
  • in those with Alzheimer's disease, there is modest benefit for risperidone at 1mg daily, and a statistically non-significant trend towards benefit for olanzapine 2.5–7.5mg daily
  • aripiprazole may also be beneficial in the treatment of agitation/aggression in Alzheimer’s disease, but there is no evidence for other antipsychotics
  • avoid quetiapine:
    • studies of quetiapine in Dementia with Lewy Bodies or Alzheimer's disease did not show any benefits in the treatment of agitation and was associated with significantly greater cognitive decline compared to placebo.
    • a study in psychosis in Alzheimer's disease, quetiapine was no better than placebo
• there are significant risks of longer term Rx with anti-psychotics in those with dementia and their use should generally be restricted to no more than 12 weeks:
  • increased mortality
  • increased stroke risk
  • cognitive decline - olanzapine and quetiapine may be particularly associated with confusion because of their anticholinergic activity
  • neurological adverse effects:
    • akaithisa
    • parkinsonism
    • falls
    • neuroleptic malignant syndrome (NMS)
  • weight gain, hyperlipidaemia, hyperglycaemia