Behavioural and Psychological Symptoms of Dementia (BPSD)

In people over the age of 65 years, 1 in 11 will have a diagnosis of dementia. Dementia is a chronic, irreversible and progressive condition, not only affecting memory but also an individual’s emotions, behaviour, and executive function. These additional symptoms have a high burden of morbidity for patients and also impact their relatives and carers. The diagnosis of BPSD encompasses the neuropsychiatric disturbances that most patients with a diagnosis of dementia will develop at some point during their illness (>80%). The symptoms of BPSD are listed below. It is a very common presentation or comorbidity to see in community services and general hospital.

This article outlines the main factors related to the presentation, aetiology, and treatment of BPSD. There are additional learning points for juniors, who may be asked to manage these symptoms out of hours.

ICD-10 codes:
F00-03 are the ICD codes for dementia and its subtypes
F02. 81 Dementia in other diseases classified elsewhere, unspecified severity, with behavioural disturbance
F05 Delirium

What are the presentations of BPSD?

-Agitation e.g. hitting out, restlessness, pacing, impulsivity and reactivity
-Wandering/ pacing e.g. out of the home, around the hospital ward
-Shouting/ calling out
-Withdrawal/apathy
-Depression/anxiety
-Disinhibition e.g. swearing, inappropriate comments, sexual disinhibition
-Hallucinations (typically visual)
-Delusions (paranoid or persecutory typically)
-Sleep or appetite disturbance (sun-downing, altered palate)

How does BPSD and dementia differ from delirium?

BPSD are the chronic changes to an individual’s psychology, functioning and cognitive process. Delirium can produce some of the above presentations but is itself acute onset, fluctuant and transient change of consciousness and is not exclusively found in dementia, unlike BPSD. Both delirium and BPSD relate and influence each other; delirium worsens an individual’s BPSD, and those with BPSD are at greater risk of developing delirium.

PBSD natural history
This diagram illustrates that delirium not only worsens the chronic and progressive BPSD but also pre-existent BPSD predisposes the individual to developing delirium. The green arrows represent insults causing a delirium e.g. infection.


Treatment Strategies

Like with all psychiatric conditions always consider a biopsychosocial approach.

Before initiating treatment, ask yourself what you are treating.
A patient wandering the ward peacefully and safely whom the ward staff want to remain in bed is not a single justifiable reason to initiate a medication. You are treating the patient’s distress or risk to self or others, not a behaviour that is merely disruptive to the work environment. If this wandering patient was agitated or aggressive then this could justify a pharmacological agent owing to this risk or self or others. With any delirium or BPSD presentation, you should be assessing whether there are any underlying contributory causes (e.g. environmental factors, pain, infection, dehydration, electrolyte disturbance, head injury, medication etc)


Does the individual have capacity?

A person is first assumed to have capacity, but during illness and as the disease progresses this is often not the case. It is important to perform a capacity assessment to consider whether these patients need to be placed under a legal framework (Mental Health Act, Mental Capacity Act) to protect their rights. Capacity is time and decision specific. The most common legislation used within the context of dementia is the Deprivation of Liberty Safeguard (DOLS), which is within the Mental Capacity Act and allows for the best interest treatment and care for an individual who lacks capacity. This should only be used when least restrictive options are unavailable

First-line: non-pharmacological treatments

The below guidelines are summarised from national sources and hence is not a comprehensive guide. Local guidelines, individual Trust policy and pharmacy input should be sought in the treatment of BPSD.

Assess for the underlying trigger(s) e.g. infection, pain, change of environment, disorientation and take measures to reduce these:
-Orientating the patient to time and place e.g. clocks in view, good lighting, curtains open or closed as appropriate, photographs of family, and personal items.
-Examining for sources of pain/ infection e.g. checking feet for ulcers/ toenail infections, musculoskeletal examination (slipped discs, arthritis)
-Being aware of sensory impairment e.g. vision and deafness. Using calm language, supporting them in a quieter environment. It is a very common scenario that hearing aids are misplaced and so these should be kept safe and labelled for the patient.
-Medications e.g. opioids and benzodiazepines, also these patients can unintentionally under/overdose due to underlying cognitive impairment, therefore it is key to ascertain their current medications and if any caregiver supervises.
-Metabolic disturbance e.g. hyponatraemia, hypo or hyperglycaemia
-Malnutrition, dietitian advice
-Occupational therapy input, involving them in activities during their stay

BPSD triggers
Second line: pharmacological treatments

Acetylcholinesterase inhibitors e.g. donepezil, rivastigmine
Melatonin in the evening
Antipsychotic medication (Risperidone), with a review every 6 weeks. If there is no benefit this should be stopped.

It is important to complete an ECG prior to initiating pharmacological therapy as drugs, such as antipsychotics can prolong the QT interval, increasing the risk of arrhythmias.

Least restrictive options should be considered, with a risk versus benefit assessment in regards to medication.

Antipsychotics have not been found to meaningfully modify the following behaviours in BPSD:

Antipsychotics have not been found to meaningfully modify the following behaviours in BPSD:
-repeated vocalisations
-Distress during personal care
-Wandering/ pacing
-Social withdrawal
-Disinhibited behaviour

NICE recommends that a trial of antipsychotics should only occur if they are a risk to themselves or others, or if they are severely distressed. Medication should not occur in isolation, but with other non-pharmacological measures to relieve their distress e.g. family photographs nearby, and clocks in view. The antipsychotic should be used at the lowest therapeutic dose and for the shortest amount of time with monitoring for efficacy and side effects The drug with the most evidence of benefit in dementia is risperidone. Used for persistent aggression moderate-severe. Other antipsychotic agents are ‘off label’ in use and would be the second-line choice in the elderly due to its more favourable side effect profile. Antipsychotics are sometimes utilised in the context of delirium on a background of dementia. However, there is a risk that these medications are not stopped in the short term, so a review should be organised once the delirium has resolved to prevent overmedication and polypharmacy. The advised medication to use in delirium in these cases is Haloperidol, at the lowest possible dose, for up to one week.

Risks with antipsychotics

-Increased risk of death
-Stroke
-Falls and fracture
-Postural hypotension
-Extrapyramidal side effects/ parkinsonian symptoms

 

Risks with Benzodiazepines

-Drowsiness
-Confusion
-Falls and fracture
-Memory problems
-Dependence risk
They are not recommended for longer than 2 weeks.

 

What can I use in an emergency?

A potential scenario that a junior can be faced with is an elderly patient with dementia who is attempting to or assaulting staff members, with a risk of non intentional self-injury. The use of non-pharmacological-based strategies here can prove ineffective or can take too long in the acute setting to facilitate. In these cases, a single dose of sedation can be given, with the least restrictive option being attempted first (oral), and it is advised to start with a low dose first:

Lorazepam 0.5-1mg oral/Intramuscular
Promethazine 25mg oral/intramuscular

Haloperidol 500mcg oral/intramuscular (avoid in Lewy Body dementia or Parkinson’s disease)

Each trust will have a guideline regarding prescribing in this scenario, and if a senior is available it is worth discussing the decision with them.

Statistics from the NHS England Toolkit:

-For every 5 to 11 patients with dementia (without psychosis), only 1 will have a reduction in their BPSD symptoms from taking an antipsychotic and the others will not.
One death is prevented for every 6 patients who have an antipsychotic discontinued which they have been on for greater than one year.
One stroke is prevented for every 37 patients with dementia who avoid 2-3 months of antipsychotic symptoms for their BPSD.

Long-term management:

The presence of BPSD symptoms is prognostic for the need for nursing care. These cases should be discussed with the multidisciplinary team, including occupational therapists, physiotherapists, dietitians and pharmacists to optimise their in-hospital care and safe discharge. In a general hospital there are the dementia and delirium team, as well as Liaison Psychiatry who you can refer to. If the patient is otherwise optimised from a physical health perspective, a specialist older adult inpatient psychiatric unit may be offered to allow for pharmacological optimisation of their BPSD, owing to their expertise and resources for this specific patient population.

Take-home messages:

-There are potentially modifiable and non-modifiable environmental factors influencing BPSD, therefore managing these patients in their known community environment when possible is beneficial.
-A carefully considered risk versus benefit decision should be made before initiating both short and long-term courses of antipsychotics in those with dementia.
-Signposting to carer and family support charities is important given the impact these symptoms have on both the patient and their caregivers.
-These patients can have difficulty communicating their physical health symptoms; it is the role of the medical team to consider precipitating factors for BPSD and to treat these before moving to psychological symptom control.
-Early involvement of the Dementia & Delirium Team, as well as the Liaison Psychiatry team in General Hospital is valuable for advice, pharmacological optimisation and for long-term management strategies.

References:

Appropriate prescribing of antipsychotic medication in dementia (NHS Toolkit for Antipsychotic prescribing)
Ward based management of behavioural and psychological symptoms of dementia, Jenny Nguyen, Santiago Martinez-Sosa, Ruth Mizoguchi
British National Formulatary
Maudsley Prescribing Guidelines

Other additional resources:

Treatment Approaches for BPSD, Psychopharmacology and Psychiatry Updates Podcast, 13th November 2022

Written by Dr Isobel Platt, (FY1)
Edited by Dr Gareth Smith (Consultant General Adult and Older Age Psychiatrist) and Dr Fergus Lewis (Psychiatry Registrar)

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