BPSD Symptom Assessment

• Dementia is a common term for major neurocognitive disorder, diagnosed by cognitive decline and functional loss as per the DSM-5.
• Various conditions like Alzheimer's, vascular dementia, frontotemporal dementia, Lewy body dementia, and Parkinson's disease can lead to dementia.
• Behavioral and psychological symptoms of dementia (BPSD) are neuropsychiatric disturbances impacting patients' functionality and quality of life.
• Supportive interventions, both non-pharmacological and pharmacological, can improve symptoms despite the lack of a cure.

Disturbances and Patient Care

• BPSD includes issues like agitation, aggression, depression, and apathy.
• Focus is placed on neurocognitive history, physical exams, and identifying manageable deficits versus emergencies.
• Clinicians can improve patient prognosis, reduce institutionalization, and support caregivers by understanding BPSD.

Objectives

• Goal is to assess environmental, psychosocial, and medical factors that worsen symptoms.
• Understand evidence-based treatments and develop strategies for managing symptoms.
• Highlights the importance of teamwork among professionals for improved patient outcomes.

Understanding BPSD

• BPSD consists of delusions, hallucinations, apathy, anxiety, depression, or disinhibition.
• BPSD includes emotional, perceptual, and behavioral disturbances similar to those in psychiatric disorders.
• BPSD is categorized into cognitive/perceptual (delusions, hallucinations), motor (pacing, aggression), verbal (yelling), emotional (depression, anxiety), and vegetative (sleep/appetite disturbances) domains.

Etiology of BPSD

• BPSD develops from the interaction of biology, prior experiences, and current environment.
• Agitation, disinhibition, and psychosis are linked to brain volume loss and reduced metabolism.
• Brain regions of focus: orbital and dorsolateral prefrontal cortex, anterior cingulate, insula, and temporal lobes.
• BPSD is also related to imbalances in neurotransmitters like cholinergic, noradrenergic, dopaminergic, serotonergic, and glutamatergic systems.
• Non-biological factors include neuroticism, PTSD, poor communication, and environmental stressors.
• Environmental factors include unmet needs, learning/behavioral issues, and patient-caregiver mismatch.

Epidemiology

• In 2016, dementia affected around 43.8 million people globally, a 117% increase from 1990, contributing 28.8 million disability-adjusted life years.
• Up to 97% of dementia patients develop BPSD, with depression and apathy being the most common, followed by delusions, agitation, and aberrant motor behaviors.
• Symptom difficulty rises over time and correlates with need for institutionalization.
• Delusions are typical in Alzheimer's, depression and apathy are typical in vascular dementia, and disinhibition and eating disturbances are typical in frontotemporal dementia.

History and Physical Examination

• The aim is to prioritize interventions, characterize symptoms, and identify contributing factors like environment, meds, discomfort, or substance use.
• The physical seeks to confirm the clinical history and uncover alternative medical issues contributing to the BPSD.
• Behavioral disturbances, known as 'sundowning', commonly occur in the evening.
• Delusions, particularly paranoid themes, are common, while hallucinations are less so.
• Patients may exhibit agitation, aggression, wandering, apathy, disinhibition, and sleep disturbances.
• Exam to identify factors worsening BPSD, like delirium or pain-related discomfort.
• Signs include altered consciousness, delirium symptoms, grimacing, guarding, fever, hypoxia, or neurological deficits.

Evaluation

• Lab work or imaging is not needed unless history/physical exam suggests alternative causes.
• Acute symptom onset may indicate need for complete blood count, electrolytes, liver/kidney function tests, urinalysis, thyroid function tests, toxicology screen, and head CT to rule out delirium.
• Bacteriuria is commonly seen in institutional settings, so test and treat only if patient has fever, dysuria, suprapubic pain, or urinary issues.

Establishing Priorities

• Assess symptom severity and nature: patients endangering themselves or others require the most intensive management, potentially including hospitalization.
• Begin with safety assessment: violent behavior, property damage, or refusal of basic needs.
• Identify delirium: caused by medical condition, medication, or substance use/withdrawal.
• Delirium needs thorough medical evaluation, often inpatient.

Characterizing Symptoms

• Caregivers should use descriptive language.
• History should include onset (acute/chronic), frequency, timing, trajectory, and relationship to environmental/medication changes.
• Temporal relationships may involve environment changes or worsening in evenings/after visits.

Reviewing Medications

• Ask about med changes preceding BPSD onset/worsening.
• Dementia patients are susceptible to central nervous system effects from meds.
• Medications like bladder antispasmodics, histamine antagonists, antidepressants, benzodiazepines, digoxin, levetiracetam, and muscle relaxants can cause agitation/apathy.
• Withdrawal from antidepressants, benzodiazepines, or opioids can cause BPSD; akathisia from antipsychotics should be considered.

Assessing Comfort

• Identify and address any uncomfortable symptoms like pain, constipation, or urinary retention.
• High pain prevalence linked to increased BPSD.
• Assess for reported and nonverbal signs of pain because patients may not express pain.
• Use assessment scales such as PAINAD or FLACC.
• Review psych history and substance use; ask caregivers about past psychiatric disorders, substance use, and medications.

Creating a Baseline

• Establish a baseline for assessing treatment effects due to symptom severity.
• The Neuropsychiatric Inventory (NPI) or the Behavioral Pathology in Alzheimer Disease Rating Scale (BEHAVE-AD) can be used.
• The NPI evaluates delusions, hallucinations, agitation, depression, anxiety, disinhibition, irritability, aberrant motor behavior, sleep disturbances, and appetite disorders.
• The BEHAVE-AD looks at activity disturbances, aggression, diurnal rhythm issues, tearfulness, depression, and anxiety.
• The Cohen-Mansfield Agitation Inventory (CMAI) assesses agitated behaviors.
• If unable to use above, describe a symptom, frequency, and distress.

Treatment and Management

• Treating BPSD involves setting, comfort, non-pharmacological approaches, and evidence-based medication trials if needed.
• Establish a baseline by identifying target symptoms.
• If delirium is present, the setting should be a hopital to allow medical interventions
• Geropsych unit referral may be needed if patient is dangerous.
• Monitor patient if dangerous, antipsychotics are usually used following benefit discussions
• Address physical causes such as pain or discomfort.

Non-Pharmacological Interventions

• May be sufficient for mild BPSD and should always accompany meds.
• Meta-analysis showed music therapy reduces BPSD overall massage reduces depression.
• Caregiver training reduces BPSD and improves well-being.
• Training focuses on understanding disturbances as communication attempts.
• The Alzheimer's Association provides training.
• A Bathing without a Battle protocol reduced agitation during care.
• Other approaches that may give benefit are aromatherapy and bright light therapy.

Pharmacological Interventions for Agitation and Aggression

• Psychotropic drugs are frequently used but have high side effect burdens.
• Wandering and repetitive vocalizations don't often respond.
• Treat underlying possible pain which is often under treated.
• Acetaminophen is a first step and excellent.
• Topical pain meds may be offered, neuropathic pain meds may be helpful.
• Avoid muscle relaxants, and tricyclic antidepressants, although opioids can cause falls.
• Tramadol is an option.
• Second-generation antipsychotics can be used although a systematic review shows effect sizes were typically small.
• Increased risk for death among elderly patients with dementia and the FDA has issued a black box warning.
• Antipsychotic meds should be an option after other treatments have failed.
• Recommended doses are mentioned in the text
• Motor effects can worsen the condition, so only use Quetiapine, Pimavanserin, and Clozapine with caution and monitoring in Parkinson's.
• Monitoring is important, discontinuation should be attempted periodically.
• Discontinuation may not worsen symptoms, but this is seen more in mild cases.
• Other meds like SSRIs can have benefits.
• Citalopram and Sertraline are associated with improvement, but also possible QTc interval.
• Start low, go slow, but increase to what is needed when treating BPSD.

Other Pharmacotherapies

• Dextromethorphan and Quinidine has shown modest benefit for agitation also with adverse effects.
• Prazosin has had no adverse effects on blood pressure in a study with participates.
• Meds that have no meaningful efficacy include Cholinesterase inhibitors, Memantine, Valproate, and benzodiazepines.
• Patients with Lewy body dementia and dementia associated with Parkinson disease may benefit from cholinesterase inhibitors.

Pharmacologic Interventions for Depression and Apathy

• Fewer studies evaluated these even though depression and apathy are the most common BPSD
• Antidepressants have an insignificant difference in their group from the placebo group.
• Patients had high rates of adverse effects.
• Citalopram and Methylphenidate give greater response without an rise in adverse effects

Other points

• Limited benefits from pharmacotherapy, therefore a system is needed for effectiveness.
• Need a clear baseline regarding the target behaviors.
• For agitation, start with Citalopram or Sertraline, then Riperidone or Aripiprazole, with consideration of an addition of acetylcholinesterase inhibitors.

Differential Diagnosis

• Delirium
• Schizophrenia
• Bipolar disorder
• Major depressive disorder
• Post-traumatic stress disorder
• Central nervous system (CNS) neoplasms

Prognosis

• Dementia patients have a worse life expecantcy.
• BPSD correlates with progression of the disease.

Complications

• Contributes to the increased burden of dementia on all.
• Can shorten life span, and put family caregivers in psychatric conditions.

Deterrence and Patient Education

• Some strategies can reduce the risk of cognitive decline.
• Dietary interventions and treatment of hypertension results in decreasing risk for dementia.
• Physical exercise can improve things.

Enhancing Healthcare Team Outcomes

• Team must partner with home caregiver
• Team must be able to identify and resolve safety risks

Test your knowledge of Behavioral and Psychological Symptoms of Dementia (BPSD). Questions cover symptom identification, history intake, environmental considerations and evaluation of BPSD. This quiz assesses understanding of BPSD in dementia patients.