Dementia Part 2: BPSD

Question 1

What is BPSD?

Answer 1

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

Question 2

What are typically the first symptoms of BPSD?

What about later stages?

Answer 2

First symptoms: depression, anxiety

Later stages: agitation, aggression

Question 3

Why is treatment of BPSD important?

Answer 3

BPSD can be extremely stressful for the pt and his/her caregiver and family

APpropriate tx can improve QoL of pt and family

Question 4

[Factors that may contribute to BPSD]

Medical

Answer 4

• 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

Question 5

[Factors that may contribute to BPSD]

Pharmacological

Answer 5

• 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

Question 6

[Factors that may contribute to BPSD]

Environmental or Social

Answer 6

• 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

Question 7

Non-pharmacological treatment approach for BPSD

• what treatment approach should be taken?

Answer 7

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

Question 8

Pharmacological treatment approach for BPSD

• Role and evidence

Answer 8

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)

Question 9

Pharmacological treatment approach for BPSD

• General guide for how to use

Answer 9

1. Initiate as a trial, not indefinitely
2. Review response to treatment, dose, and adverse effects at least every 3 months
3. Routinely withdrawn, slowly, after 3 months of improved symptoms unless symptoms were severe or due to a comorbid psychiatric disorder (e.g., bipolar depression)
4. Restart at the lowest effective dose If symptoms return following a withdrawal; schedule further trial withdrawal in 3-6 months

Question 10

BPSD Target Behavior: Agitation and Aggression

• Describe presentation

Answer 10

Can be verbal, e.g., complaining, angry statements, threats

Or physical, e.g., resistiveness to carers, restlessness, spitting, hitting out

Question 11

BPSD Target Behavior: Agitation and Aggression

• Non-pharmacologic

Answer 11

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

Question 12

BPSD Target Behavior: Agitation and Aggression

• Pharmacologic

Answer 12

• Antipsychotics
• SSRI: Citalopram (shown to reduce agitation in pt with AD)

Question 13

BPSD Target Behavior: Depression

• Describe presentation

Answer 13

• More prevalent in early stages
• May present as sadness, tearfulness, pessimistic thoughts, withdrawal, inactivity, fatigue

Question 14

BPSD Target Behavior: Depression

• Non-pharmacologic

Answer 14

• Exercise
• Social engagement
• Cognitive behavioural therapy (CBT)

Note that severe depression may require input from clinician with experience

Question 15

BPSD Target Behavior: Depression

• Pharmacologic

Answer 15

SSRI

Question 16

BPSD Target Behavior: Anxiety

• Describe presentation

Answer 16

In later stages, anxiety may be an exaggerated response to separation from family, reduced capacity to make sense of the environment

Question 17

BPSD Target Behavior: Anxiety

• Non-pharmacologic

Answer 17

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

Question 18

BPSD Target Behavior: Anxiety

• Pharmacologic

Answer 18

SSRI

Question 19

When might CBT be considered?

Answer 19

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.

Question 20

BPSD Target Behavior: Apathy

• Describe presentation

Answer 20

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

Question 21

BPSD Target Behavior: Apathy

• Non-pharmacologic

Answer 21

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

Question 22

BPSD Target Behavior: Psychotic symptoms

• Describe presentation

Answer 22

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

Question 23

BPSD Target Behavior: Psychotic symptoms

• Non-pharmacologic

Answer 23

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

Question 24

BPSD Target Behavior: Psychotic symptoms

• Pharmacologic

Answer 24

• Antipsychotics
• SSRI: Citalopram may improve delusion symptoms

Question 25

BPSD Target Behavior: Wandering - Describe presentation

Answer 25

May be related to agitation Present as circular pacing b/w two points, random or direct to a location without diversion *poses safety concerns*

Question 26

BPSD Target Behavior: Wandering - Non-pharmacologic

Answer 26

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

Question 27

BPSD Target Behavior: Nocturnal disruptions - Describe presentation

Answer 27

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

Question 28

BPSD Target Behavior: Nocturnal disruptions - Non-pharmacological

Answer 28

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.)

Question 29

What are the BPSD behaviors that occur more commonly with Lewy Body dementia?

Answer 29

- Apathy - Psychotic symptoms: vivid visual hallucinations - Nocturnal disturbances

Question 30

Use of SSRIs

Answer 30

Indicated for depression and anxiety Citalopram - shown to reduce agitation, improve delusions Consider adverse effects: - dose-dependent risk of increased QT PROLONGATION - worsening cognition

Question 31

Use of TCAs

Answer 31

Generally not used bc of anticholinergic effects that may further disrupt cognition

Question 32

Use of antipsychotics - Indication

Answer 32

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*

Question 33

Use of antipsychotics - Effectiveness

Answer 33

- 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)

Question 34

Use of antipsychotics - Concerns with antipsychotics use

Answer 34

- **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

Question 35

Use of antipsychotics - Duration of use (NICE guideline)

Answer 35

- 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

Question 36

Use of antipsychotics - Common SEs to look out for

Answer 36

- 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)

Question 37

Use of antipsychotics - Based no NICE guidelines, which antipsychotics can be used

Answer 37

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

Question 38

What about other anxiolytics like BZDs such as diazepam or other sleep medications?

Answer 38

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