BPSD: Management and Interventions

• Management of Behavioral and Psychological Symptoms of Dementia (BPSD) requires appropriate setting, discomfort treatment, non-pharmacological interventions, and evidence-based pharmacological therapies if needed.
• Interventions should begin after establishing a baseline by identifying and quantifying target symptoms, unless patients endanger themselves or others.

Choosing an Appropriate Setting and Addressing Discomfort

• Delirium patients are best managed in a hospital for medical evaluation due to the potential need for parenteral medications.
• A geropsychiatry unit referral suits medically stable patients endangering themselves or others, especially if pharmacotherapy is refused or ineffective such as aggression with injury, refusing fluids or basic hygiene, suicidal behavior.
• Pending transfer of dangerous patients, monitoring with one-on-one observation and antipsychotic medications are generally used after a risk/benefit discussion with surrogates or guardians.
• Assess and treat all patients for causes of discomfort (e.g., pain, constipation, urinary retention, room temperature) before BPSD-specific interventions.

Non-Pharmacological Interventions for BPSD

• Non-pharmacological interventions may suffice for mild BPSD and should always accompany pharmacotherapy.
• Geriatrics organizations and experts advocate for non-pharmacological interventions for BPSD
• Meta-analysis of 10 randomized controlled trials in patients with moderate to severe dementia found no benefit, except for music therapy in reducing overall BPSD and massage therapy in reducing depression.
• Caregiver training focuses on understanding behavioral disturbances as responses to discomfort or unmet needs to communicate.
• Training includes creating soothing environments with optimal stimulation levels and responding in ways that de-escalate problematic behaviors (distraction, clear instructions, simple choices without rewarding behaviors).
• The Alzheimer Association offers online and in-person caregiver training, providing professional and peer support.
• Training caregivers in a protocol called "Bathing without a Battle" can reduce agitation, bathing time, and antipsychotic use for patients whose BPSD occurs during personal care
• Other non-pharmacological approaches, while not consistently effective, may benefit individual patients and rarely have adverse effects.
• Effective interventions include aromatherapy, bright light therapy for circadian disturbances, massage, multisensory stimulation, and reminiscence therapy (reviewing the past via conversation, photos, or music
• Interventions with anecdotal effectiveness for agitation include giving patients simple tasks like folding laundry, busy lap quilts, weighted blankets.
• A clinical trial (Clinical Trials.gov ID NCT03643991) evaluates weighted blankets, stating non-pharmacological approaches are generally well-tolerated, but music therapy has caused rare cases of worsening agitation.

Pharmacologic Interventions for Agitation and Aggression

• Psychotropic medications are frequently use to treat BPSD despite the high side effect burden and the modest benefits.
• Non-drug-related therapies are best for wandering and repetitive vocalizations due to their lack of response to pharmacotherapy
• Pharmacological approaches depend on the nature and severity of symptoms, such as agitation, aggression, and psychosis.
• Empiric treatment of painful conditions can be effective, since 49% of dementia patients experience pain, but only 20%-40% receive analgesics, compared to 60%-80% of patients without dementia. Clinicians may under-recognize and patients may under-report pain
• An 8-week trial studied the effect of empirical pain treatment in dementia-related patients with agitation; starting with routine acetaminophen (3 g daily), and, if insufficient, stepping up to low-dose morphine (up to 20 mg daily), buprenorphine patch (up to 10 mcg hourly), or pregabalin (up to 300 mg daily).
• Patients with agitation showed a 17% reduction (similar to risperidone), with no adverse effects on cognition or physical functioning. Which suggests that benefits are not do to sedating
• Initiating routine acetaminophen (up to 3 g/day) is a good first step; consider topical therapies (lidocaine, diclofenac gel, or methyl salicylate cream, because they can be effective if a localized source of pain is suspected.
• Duloxetine, Gabapentin, or Pregabalin can be helpful for neuropathic pain, but are associated with an increase in falls.
• Avoid using muscle relaxants, chronic NSAIDs, and tricyclic antidepressants.
• Although opioids can also contribute to falls and fractures, Transdermal Buprenorphine may be the safest alternative and does not worsen renal insufficiency, which is common in older adults.

Antipsychotics

• Second-generation antipsychotics (risperidone, olanzapine, quetiapine, and aripiprazole) are the mainstay of treatment for agitation and aggression; however, they have small effect sizes (0.15 to 0.30 in most studies), and Quetiapine generally did not differ from placebo
• Common adverse effects include extrapyramidal symptoms, cerebrovascular events, somnolence, urinary tract symptoms, death, and worsening confusion with Quetiapine and Olanzapine
• Risk for death is increased in elderly patients with dementia who used antipsychotics (3.5% vs. 2.3% in placebo, mainly due to cerebrovascular disease and infections).
• Antipsychotics should only be an option when non-pharmacological interventions and pharmacological interventions, such as pain control and selective serotonin reuptake inhibitors (SSRIs), (SSRIs) have been ineffective or if the patient is a harm to themselves or others.
• Starting doses of antipsychotics include: Aripiprazole 2 mg daily and 15 mg daily; Olanzapine 2.5 mg daily and 10 mg daily; Quetiapine 12.5 mg twice daily and 100 mg twice daily; and Risperidone 0.25 mg twice daily and 1 mg twice daily
• Doses can be increased in small increments every 2 weeks after insufficient improvement, based on prospective ratings from caregivers
• Avoid using antipsychotics other than Quetiapine, Pimavanserin, and Clozapine in Lewy body dementia and dementia associated with Parkinson disease because of their risk to worsen motor symptoms.
• Clozapine requires special monitoring and reporting and Pimavanserin is approved by the Food and Drug Association for the treatment of psychosis related to Parkinson disease.
• Standard starting dose of pimvanserine is 34 mg. Side effect profile includes: QT interval prolongation and black box warning for increased risk of death in geriatric patients with dementia.
• Periodic (every 3 to 6 months) attempts to taper and discontinue the medication are necessary and patients receiving antipsychotic medications require monitoring for adverse motor effects,
• Discontinuation is more difficult for patients who have had severe symptoms; however, antipsychotic discontinuation does not result in worsening of BPSD (evidenced by one longitudinal study wherein, about 80% of patients on long-term antipsychotics were successfully discontinued without increased BPSD or use of as-needed medication

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Compared to antipsychotics, benefits have been seen in the use of other medications, such as, Citalopram and Sertraline
• Rate of adverse effects similar to placebo was demonstrated with Citalopram and Sertraline, but Trazodone was ineffective.
• Patients had an average increase in QT interval of 18 ms and antidepressant dosing strategies were the same as for depression
• Common SSRI adverse effects include nausea and hyponatremia.
• It is better to "start low, go slow, but go as high as you need to go" when treating mild to moderate BPSD with SSRIs because too-rapid titration can worsen agitation
• Should start Citalopram at 10 mg daily and Sertraline at 25 mg daily.
• Target symptoms and their baseline frequency/severity should undergo assessment before starting the medication, and patients should be followed for 2 to 3 weeks for response and tolerability.
• If no benefit exists but also no adverse effects, Citalopram dosing should increase to 20 mg and Sertraline to 50 mg.
• Sertraline may be further increased to a maximum dose of 200 mg daily; however, the maximum recommended dose of Citalopram is 20 mg daily due to QTc prolongation at higher doses.

Other Pharmacotherapies

• The combination of Dextromethorphan and Quinidine, which has approval in the U.S. and Europe for the pseudobulbar effect, has modest benefit for agitation but significant adverse effects, especially falls.
• For BPSD, Prazosin (average dose of about 6 mg daily) without adverse effects on blood pressure can be beneficial after use in a study with 22 participants.
• Medications with no clinically meaningful efficacy for agitation or aggression include Cholinesterase inhibitors, Memantine, Valproate, and benzodiazepines.
• Exception: Cholinesterase inhibitors in the dementia population as a whole is the possible benefit

This lesson explores the management of Behavioral and Psychological Symptoms of Dementia (BPSD), emphasizing initial steps, assessment, and the role of non-pharmacological interventions. It covers when to refer patients for geropsychiatry and the importance of caregiver training. Specific interventions like 'Bathing Without a Battle' are also discussed.