Behavioural and Psychological
Symptoms of Dementia
Non-pharmacological and
pharmacological approaches
Dr Joy Ratcliffe, Consultant Psychiatrist
Dr Julie Colville, Clinical Psychologist
Lorraine Smith, Advanced Practitioner
Manchester Mental Health and Social Care Trust
& CMFT
BPSD
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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
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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
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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 sleepwake cycles important drivers for 24hr
care
 BPSD also associated with worse outcome
and illness progression
 Adds significantly to direct and indirect
care costs
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Multiple Factors that influence Behaviour
Non Pharmacological
management of BPSD –
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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
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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.
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Principle of Behaviour Management
- Observing and Describing
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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
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What are we targeting:
 Frequency/ severity
 High frequency/ low severity (lower consequences)
 Low frequency/high severity (higher consequences)
 High frequency/High severity (highest
consequences)
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What are ‘contingencies? e.g. positive and negative
reinforcement
Biological Management
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Treat underlying cause
Psychotropics?
Severity
Risk
Distress
Medical comorbidity / other meds esp vascular risks
Capacity
Views carers
Assessment
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Delirium (caution not to miss hypoactive)?
PINCH ME (pain, infection, nutrition, constipation,
hydration, medications, environment)
PAIN (physical / pain, activity related, iatrogenic, noise /
environment)
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START LOW GO SLOW
Review target symptoms and adverse effects
How long to treat for
Gradual withdrawal
Licensed?
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Psychosis- risperidone (0.25-0.5mg bd), olanzapine (2.510mg), 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)
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CAUTION WITH ANTIPSYCHOTICS- quetiapine,
aripiprazole, clozapine
1st choice cholinesterase inhibitors
Clonazepam for REM sleep disorders
Vascular Dementia (VD)
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Cholineterase inhibitors and memantine not licensed but
majority of cases mixed AD / VD
Cholinesterase Inhibitors
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Bradycardia
Prolonged QTC
LBBB
Gastric bleeding risk (pmhx, aspirin, NSAIDS, warfarin)
COPD / asthma
Epilepsy
Antipsychotics
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ECG, QTC, other changes
Vascular risks
Increase cognitive impairment
Antidepressants
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Sedation
GI bleeding
Na
Falls (inc SSRIs)
Citalopram –QTC, max dose 20mg
Anticonvulsants
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Limited evidence
Adverse effects
Case Example
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Case example
75, female, vascular dementia, 24 hr care for 12
months
Complaints from care staff
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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
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Case Example
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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
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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?