Behavioural and Psychological Symptoms of Dementia

Non-pharmacological and pharmacological approaches

Dr Joy Ratcliffe, Consultant PsychiatristDr Julie Colville, Clinical PsychologistLorraine Smith, Advanced PractitionerManchester Mental Health and Social Care Trust

& CMFT

BPSD What is it?

Heterogeneous group non- cognitive behaviours Not a diagnostic category – but very important Think as a list of disturbed behaviours e.g.

Wandering Agitation Sexually disinhibited behaviours Aggression Paranoia/suspicion

Eliciting psychological/psychiatric problems e.g. depression, anxiety, delusional ideas/psychosis

All adds to risk

BPSD Behavioural and psychological symptoms of

dementia (BPSD) are common They can be problematic in clinical practice and can

form a significant part of the day-to-day work of primary care teams, later life psychiatry teams. CMHTs, inpatient and community settings.

We need to improve recognition and management of BPSD

Improved management can have a positive impact on the quality of life of our patients and carers both at home and in nursing/residential setting s

Positive management may also delay 24hr care

BPSD - Prevalence Vary widely Approx 2/3rds will experience BPSD at any one

time Approx 1/3 in the ‘clinically significant ‘range Can rise to 80% in care homes 20% for BPSD in Alzheimer’s disease BPSD tends to fluctuate with psycho-motor

agitation most common and persistent

BPSD - Impact BPSD rather than cognitive features are

the major causes of care giving burden Paranoia, aggression, disturbed sleep-

wake cycles important drivers for 24hr care

BPSD also associated with worse outcome and illness progression

Adds significantly to direct and indirect care costs

Multiple Factors that influence Behaviour

Non Pharmacological management of BPSD –

Must be ‘collaborative’ - Needs thorough Assessment - multiple factors Need nursing home staff to input into assessment

e.g. what do they know about their client? Need staff e.g. Nursing Home to play key part e.g.

ABCs - helps identify factors such as over/under stimulation, pain etc

Need staff to implement and monitor plans Care Staff do need training in dementia Need medical staff to ensure physical problems

optimally treated e.g. infection, pain

Non Pharmacological management of BPSD

Understanding client’s history, lifestyle, culture and preferences, including their likes, dislikes, hobbies and interests.

Providing opportunities for the person to have conversations with other people.

Ensuring the person has the chance to try new things or take part in activities they enjoy.

Environmental factors-signage, lighting, photographs.

Reminiscence therapy.

Shared Care

Shared care plans to enhance communication and collaboration.

Discuss shared care plan.

Principle of Behaviour Management - Observing and Describing

What is happening When does it happen How often does it happen Who is there when it’s happening What is communication like Why do you think it is happening Any other observations

Principles of Behaviour Management- Contingencies

What are we targeting: Frequency/ severity

High frequency/ low severity (lower consequences) Low frequency/high severity (higher consequences) High frequency/High severity (highest

consequences)

What are ‘contingencies? e.g. positive and negative reinforcement

Biological Management• Treat underlying cause• Psychotropics?• Severity• Risk• Distress• Medical comorbidity / other meds esp vascular

risks• Capacity• Views carers

Assessment Delirium (caution not to miss hypoactive)? PINCH ME (pain, infection, nutrition,

constipation, hydration, medications, environment)

PAIN (physical / pain, activity related, iatrogenic, noise / environment)

START LOW GO SLOW Review target symptoms and adverse effects How long to treat for Gradual withdrawal Licensed?

• Psychosis- risperidone (0.25-0.5mg bd), olanzapine (2.5-10mg), quetiapine (25-150mg) amisulpiride, aripiprazole, zuclopethixol

• Aggression- as above, trazadone, clomethiazole• Agitation / anxiety- as above, citalopram,

mirtazepine, memantine (AD), pregabalin• Depression- sertraline, citalopram, mirtazepine• Mania- valproate, lithium, antipsychotics• Apathy- sertraline, citalopram, cholinesterase

inhibitor (D, R, G)• Sleep- temazapam, zopiclone, melantonin

Lewy Body Dementia (LBD) CAUTION WITH ANTIPSYCHOTICS- quetiapine,

aripiprazole, clozapine 1st choice cholinesterase inhibitors Clonazepam for REM sleep disorders

Vascular Dementia (VD) Cholineterase inhibitors and memantine not

licensed but majority of cases mixed AD / VD

Cholinesterase Inhibitors Bradycardia Prolonged QTC LBBB Gastric bleeding risk (pmhx, aspirin, NSAIDS,

warfarin) COPD / asthma Epilepsy

Antipsychotics ECG, QTC, other changes Vascular risks Increase cognitive impairment

Antidepressants Sedation GI bleeding Na Falls (inc SSRIs) Citalopram –QTC, max dose 20mg

Anticonvulsants Limited evidence Adverse effects

Case Example Case example 75, female, vascular dementia, 24 hr care for 12

months Complaints from care staff

agitation ‘breathless’ hyperventilating, ‘attention seeking’ – calling every 5 mins Saying pain (but where?) toileting – incontinent faeces falls, (needing extra monitoring)

Case Example

PERSONAL – lived alone many years – over stimulated

- remove to quieter environment DEMENTIA – vascular with periods

disorientation unable to express distress (language)

- try and reorientation/reassurance spend time with

Case Example PHYSICAL – incontinence = ‘overflow’

compacted, meds 2 x laxatives and codeine (opposite actions?), pain (unable to express)

- Elimination of acute physical illness as triggers for BPSD. Reviewed with Advanced Practitioner - GP to check pain and review meds,

FALLS – interaction meds Trazadone and codeine , over –sedated

- meds review, Falls Team, Physio, frame

Case Example PSYCHOLOGICAL – fear of falling exacerbated

by previous falls, highly anxious (premorbidly – calling ambulance, GP, police etc)

Ongoing assessment by Psychology, anxiety still prominent

Linked to disorientation and/or premorbid anxiety Activity/distraction, optimal? Co pharmacological treatments – optimally

treated?