Dementia – managing
behavioural and psychological
symptoms
Dr. Jonathan Hare
Consultant Old Age Psychiatrist
Barnet, Enfield & Haringey Mental Health Trust
Dr Robert Tobiansky
Dementia
A syndrome due to disease of the brain
usually of a chronic or progressive nature
 Multiple disturbances of higher cortical
function
 Global impairment: intellect, memory,
personality
 Changes in emotional control, social
behaviour, motivation
 In clear consciousness
 Decline in usual functional abilities
Dementia
Many causes but commonest are:
 Alzheimer’s Disease
 Vascular Dementia
 Lewy Body Dementia
 Alcohol related dementia
 Frontotemporal dementia
Dementia: general signs &
symptoms
 Early stages: memory impairment, loss of
planning, judgement, difficulty with
administrative tasks etc
 intermediate impaired basic ADL can’t learn
new information, increasing disorientation
time & place
 increased risk of falls and accidents due to
confusion and poor judgment
Dementia: signs & symptoms
 severe dementia: no ADL skills, totally
dependent for feeding, toileting, &
mobilising. Severe global cognitive
impairment
 risk of malnutrition and aspiration
 poor mobility & malnutrition increases risk of
pressure sores
 Seizures, dehydration, malnutrition,
aspiration, pressure sores
 death from infection (resp., skin, UTI etc)
Dementia: signs & symptoms
 Behavioural problems (BPSD):
 Persecutory delusions, suspiciousness in c.
25%
 wandering, aggression, agitation
 Depressive symptoms in c. 60%
 Depression in c. 25%
Delirium: DSM 4 criteria
 Disturbance of consciousness with reduced
ability to focus, sustain or shift attention
 Change in cognitive function not due to preexisting or evolving dementia
 Development over short period of time –
usually hours or days & tendency to fluctuate
during course of day
Delirium: causes
 Infection
 Drugs (prescribed & illicit, intoxication or
withdrawal)
 Organ failure (cardiac, resp., hepatic, renal)
 Electrolyte disturbance (dehyd. Na/Ca/K)
 Endocrine & metabolic – thyroid, glucose
 CNS- CVA, subdural, SOL
 Nutritional – thiamine deficiency
 Malignancy
 Hypothermia
Delirium: management
 Clarify history
 Assessment of physical & mental state
 Identify & treat underlying cause
 May need to treat neuropsychiatric
symptoms with modest doses of sedatives or
antipsychotics
 Well-lit, quiet room, address sensory
impairment
Levels of evidence
1.Metanalysis
2.Randomised placebo controlled trials
3.Other studies
4.Expert opinion,
National guidance, local protocols, expert
opinion etc
BPSD
 Behavioural and Psychological Symptoms in
Dementia
BPSD symptoms include:
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Agitation
Aggression
Repetitive vocalisations
Sexual disinhibition
Wandering
Shadowing
Depression
Anxiety
Apathy
Delusions
Hallucinations
Irritability
Restlessness & overactivity
BPSD
 Very common in people with dementia
 Almost all will have at least one symptom at
some point in illness
 Distress to patient & carers
 Associated with increased institutionalisation
 Faster rate of decline
 Increased mortality
 Increased stress for care staff
NICE guidance CG42
1.7.1.1 assess PWD who develop behaviour that challenges
the person's physical health
‐ depression
‐ possible undetected pain or discomfort
‐ side effects of medication
‐ individual biography, including religious, spiritual & cultural
‐ psychosocial factors
‐ physical environmental factors
‐ Individually tailored care plans, recorded & reviewed regularly
1.7.1.2 Approaches that may be considered include:
‐ aromatherapy
‐ multisensory stimulation
‐ therapeutic use of music and/or dancing
‐ animal-assisted therapy.
Aetiology of BPSD (after Brodarty)
 Biological
 Psychosocial
 Environmental
Biological potential causes
 Frontal pathology – disinhibition, depression
 Basal ganglia lesions-delusions
 Temporal lobe pathology – delusions,
hallucinations
 Locus coeruleus – psychosis, depression
 Previous / current psychiatric disorder:
depression / anxiety / psychosis
Biological causes
 Acute medical illness eg UTI, RTI causing delirium
 Medication
 Pain syndromes
 Constipation
 Urinary retention
 Sensory impairment
 Basic needs – tiredness, hunger, thirst
Psychological causes
 Previous psychiatric illness
 Premorbid personality- no meaningful
correlations
 Frustration
 fear
 Interpersonal / reaction of others
Environmental factors
 Overstimulation
 Understimulation (boredom)
 Overcrowding
 Inconsistent care givers, high staff changes
 Provocation by others
“Something must be done”
 Who’s problem is it?
 What is the behaviour?
 When does it occur?
 Where does it occur?
 Try to understand the behaviour, why is this
person presenting like this at this time?
 Intervene if behaviour results in distress or
risk to patient or others
Before intervening
 Clarify the nature of the problem
 Document /keep ABC chart of behaviour
 Confirm most difficult challenging behaviour
 Are there triggers?
 Exclude non-dementia causes
 treat medical disorders & any causes of
disability (mobility, vision, hearing etc )
 NB PAIN!
Environment
 Modify environment (nidotherapy)
 Adequate space
 Privacy available
 Personalised space
 Avoid over / under stimulation
 Lighting, colours, furnishing, architecture
 Size of unit
 Mix of residents
 staff
Possible Interventions
 Bright light therapy- weak evidence
 Aromatherapy (lemon balm, lavender)
moderate evidence, cochrane review
 Snoezelen:multisensory stimulation (modest
evidence)
 Music therapy
 Person centred / dementia care mapping
 My life package
 Cognitive stimulation therapy
Interpersonal
 Staff education, support & training
 Dementia care mapping
 Person centred care (Kitwood) individualised care
planning, fairly good evidence can reduce BPSD
 Psychoeducation for carers
 Behaviour management techniques
Therapeutic approaches
 Reminiscence groups
 Relaxation training
 Behavioural management techniques
Medication
 Medication for Behavioural & Psychological
Symptoms in Dementia (BPSD)
Medication:
Antidementia drugs
-cholinesterase inhibitors:
donepezil (Aricept)
rivastigmine (exelon)
galantamine (reminyl)
-Memantine (Ebixa)
Licenced drugs
 Risperidone is the only licensed drug for the
treatment of BPSD (aggression)
 Antidementia drugs are licensed for
treatment of cognition not behaviour in
restricted severity groups
• Cholinesterase inhibitors for mild to moderate AD
• Rivastigmine for mild to moderate Parkinson’s
Disease Dementia
• Memantine for moderate to severe AD
Other medication for BPSD
Antidepressants
Anxiolytics
Hypnotics
Antipsychotics
Anticonvulsants
Cholinesterase inhibitors for BPSD
 Systematic review & meta-analysis
 Statistically significant vs placebo
 Modest clinical benefit
 Biggest response on individual symptoms,
apathy, hallucinations,
Memantine for BPSD
 Several RCTs vs placebo (eg Reisberg,et al; Tariot
et al; Van Dyck et al; Gauthier et al)
 Small effect aggression, agitation
Depression in dementia:
Cochrane review
Antidepressant
Dose
Study
Outcomes
Sertraline
25-150mg
Lyketos et al 2003
Clomipramine
25-100mg
Petracca et al 1996
Imipramine
50 -150mg
Reifler et al 1989
N
Duration
44
12 wks Positive
21
6 wks
Positive
61
8 wks
n.s.
Antidepressants in dementia
 Study of Antidepressants for Depression in
Dementia (SADD) study: Banerjee et al Lancet 2011
 Mirtazapine & sertraline vs placebo
 No significant benefits
CATIE-AD study Citalopram
effects on BPSD Siddique et al 2009
 Trend reduced irritability & apathy
 Reduced hallucinations
Antidepressants in dementia:
conclusion
 Modest evidence efficacy
 May benefit agitation
Antipsychotics in dementia
 RCT evidence:
 Haloperidol
 Risperidone
 Quetiapine
 Olanzapine
 Aripiprazole
 CATIE-AD: 42 sites, 421 pts randomised to
olanzapine, quetiapine, risperidone, placebo
Antipsychotics in dementia
 Meta-analysis evidence: medium effect size
 Benefit for severe aggression, delusions
Antipsychotics in dementia
 2-3 x increased risk cerebrovascular adverse
events
 1-2% increased risk death
Defensible prescribing of
antipsychotics in Dementia
 Consider non-pharmacological alternatives
 Address vascular risk factors
 Consent / capacity / best interests
 Discuss risks & benefits with patients or carers
 Identify target symptoms (psychosis, hostility,
aggression)
 Choose effective drug & dose
 Choose time-frame during which to assess benefits
(discontinue if no evidence benefit or if harm)
 review need & aim to withdraw in c 3/12 if possible
Doses of antipsychotics
start
range
 Risperidone
 Olanzapine
 Quetiapine
 Aripiprazole
0.25mg
2.5mg
25mg
2mg
0.5 to 2mg/day
2.5-10mg /day
25-100mg
5-10mg
Anticonvulsants in dementia
 Review of RCTs
 Weak to modest evidence carbamazepine
further trials needed
 Poor evidence / negative for valproate
mostly no significant difference
 Adverse events more frequent in treatment
groups
Benzodiazepines
 RCTs: Benzos reduce agitation
 Adverse effects: falls, sedation, worsen cognition
Using medication in BPSD
 Pharmacotherapy can be effective for BPSD
 First step: identify target symptoms
 Correct reversible factors
 Try environmental & psychological
approaches first unless high risk of harm to
self / others
 Use medication carefully, “start low go slow”
 Review treatment
Thank you