BPSD: Symptoms, Diagnosis, and Management

• BPSD is behavioral and psychological symptoms of dementia

Continuing Education Activity

• Dementia, or major neurocognitive disorder (MND) is diagnosed through DSM-5 criteria
• MND is cognitive decline and a decreased ability to perform daily tasks
• Etiologies include Alzheimer's, vascular, frontotemporal, Lewy body, and Parkinson's diseases
• BPSD includes neuropsychiatric disturbances causing functional loss
• Supportive and pharmacological interventions can help
• This activity addresses agitation, aggression, depression, and apathy
• It enhances patient care through a neurocognitive focus on history and physical exam
• It provides guidance on managing deficits and emergencies
• Clinicians will navigate BPSD complexities, impacting prognosis, institutionalization, and caregiver well-being
• Professionals may improve patient outcomes
• Objectives include evaluating factors contributing to BPSD, identifying evidence-based interventions, creating a systematic strategy, and explaining interprofessional collaboration

Introduction

• BPSD include delusions, hallucinations, apathy, anxiety, depression, or disinhibition
• Symptoms are classified into cognitive/perceptual, motor, verbal, emotional, and vegetative domains

Etiology

• BPSD relates to interactions between biology, experiences, and environment
• Dementia-related agitation, disinhibition, and psychosis are associated with volume reductions and decreased metabolism in brain regions mediating emotional regulation, self-awareness, and perception
• BPSD correlates with neurotransmission imbalances
• Non-biological determinants include neuroticism, PTSD, caregiver communication, and environmental factors
• Environmental factors include the categories of unmet needs, behavior or learning, and patient-environment mismatch

Epidemiology

• The worldwide prevalence of dementia was 43.8 million in 2016
• Individuals with dementia may develop BPSD, commonly depression or apathy
• Delusions, agitation, and aberrant motor behavior occur in about a third of patients
• Symptom severity increases with institutional placement
• Alzheimer's has delusions, vascular dementia has depression and apathy, and frontotemporal dementia has disinhibition and eating disturbances

History and Physical

• Prioritize the nature and urgency of interventions, characterize symptoms, and identify reversible exacerbating factors
• These factors include environmental characteristics, medications, discomfort, substance use, and pre-morbid psychiatric disorders
• Physical examination aims to confirm historical data and identify an contributing psychiatric or medical conditions
• Evening behavioral disturbances are known as 'sundowning.'
• Psychiatric sequelae observed is delusions.
• Additional symptoms include agitation, aggression, wandering, apathy, disinhibition, sleep disturbances, and depression
• The physical examination documents symptoms and identifies factors worsening BPSD

Evaluation

• Evaluation with lab or imaging is unnecessary for patients with gradually worsening BPSD
• Acute or subacute symptom onset can be tested with blood count, electrolytes, liver/kidney function, urinalysis, thyroid function, toxicology, and head CT
• Long-term staff may attribute BPSD to UTIs though diagnostic evaluation should be limited to patients with fever, dysuria, suprapubic pain, or urinary problems

Establish Priorities

• Characterize the severity and nature of symptoms is priority; hospitalization for aggressive behavior
• History should begin with an assessment of safety
• Delirium is caused by a condition, medication, or non-prescribed CNS- substance and needs evaluation and treatment

Characterize Symptoms

• Caregivers should describe what they see rather than using generic terms such as "agitation" or "depression"
• Elements of history include onset, frequency, timing, and trajectory of disturbances and relationship to changes

Review Medications

Medications changes can affect the worsening of BPSD.

• Be aware of bladder antispasmodics and histamine antagonists that affect cognition and behavior
• Antidepressants, benzodiazepines, digoxin, levetiracetam, and muscle relaxants contributing to agitation and apathy

Assess Comfort

• Review systems should address discomfort, including pain, constipation, and urinary retention, due to pain present for patients experiencing BPSD
• Past medical history review for painful conditions and self reported pain
• PAINAD or FLACC are reliable for evaluating and tracking pain

Create a Baseline

• Important to establish clear baseline for assessing treatment effects and BPSD
• Standardized instrument use with the NeuropsychiatricInventory (NPI) or behavioralpathology inAlzheimer Disease Rating Scale (BEHAVE-AD), based on interveiws with caregivers is important

Treatment / Management

• Management of BPSD involves choosing appropriate setting, treating discomfort, implementing non-pharmacological interventions, and pharmacological therapies if needed
• Unless patients endanger themselves or others, interventions should be identifying and quantifying target symptoms

Choose an Appropriate Setting

• Patients with delirium are best managed in a hospital
• Referral to geropsychiatry is appropraite for patients endangering themselves or others with pharmacotherapy that ineffective
• Dangerous patients get on-on-one observations, and antipsychotic medications will usually be necessary

Treat Discomfort

• Patients should be assessed and treated for causes of discomfort, pain, constipation, urinary retention, room temperature and others

Non-Pharmacological Interventions for BPSD

• Experts advocate the use of interventions for BPSD
• Meta-analysis of 10 randomized controlled trials in patients with moderate to severe dementia found no benefit besides music and massage tehrapy
• Training focuses understanding behavior disturbances as responses to communication, levels of stimulation and communication

Caregiver Training

• Alzheimer's Association offers models and classes to support
• Randomized study showed training caregivers to battle reduced agitation, bath time and antipsychotic use
• Non drug interventions consist of aromatherapy, light therapy, massage and therapy where patients review their past
• Give patients simple tasks such as quilts and weighted blankets

Pharmacologic Interventions for Agitation and Aggression

• Medications are used to treat BPSD though side effects are high
• Primary focus is on agitation, aggression and psychosis treatment since this manifests to cause the most distress
• Painful conditions consist of painful condition
• Acetaminophen is started if not recieving analgesics. Followed by morphine, transdermal patch or pregabalin
• Pain relief reduced agitation comparable to an antipsychotic
• Patients should initiate acetaminophen and safe topical or neuropathic creams

Antipsychotics

• 2nd generation which consists of risperidone, olanzapine, quetiapine and aripiprazole
• High risk for death
• For those who have harm for themselves, its an option drug intervention such as pain control and selective serotonin reuptake inhibitors and non pharm is needed, for BPSD elderly

Selective Serotonin Reuptake Inhibitors (SSRIs)###

• Other drugs in the market for agitation and ssri or sertaline- ssri is needed. Its wise to go with geropsychoiatry maxisms which has showed common ssri effects

Other pharamcies

• Combination of Dextromethorphan Quinindine is apporved for pseudolumar
• Prazsosin beneficial for BPSD without adverse effects on blood pressure in a study with 22 participants.
• Exception to the negative findings regarding cholinesterase inhibitors in the dementia population

Pharma Intervetions for Depression and Apathy

• While the 2 topics are most common in BPSD fewer studies have examined outcomes of pharmacotherapy
• In elderly patients without dementia the Citalopram and Methyphenidate has shown to be for elderly patients with no dementia

Approach to pharmacotherapy for BPSD

• Given limited overall benefits should be critical , established and clear baseline for treatment and recommended
• Educate and understand the change is often gradial and should be discontinued if no change of benefits were shown

Treatment Recovery / Management

• Neurostimulation Therapies may have a role in refactory patients. Transcanical Direct current showed no benefit while tranical magnetic stimulation showed benefits
• Electroconslusive therapy is effective for both depression and aggression in patients with dementia

Differentual Diagnosis

• Consist of (Delurium, Schizophrienia, Blpolar disorder, Ptsd and Major depression
• Delrium Demonstrates Acure Onset and Fluctuating to Ptsd Delrium is typically less prominent.

Prognosis

• Dementiia associated with singicfnicant decareased if Expectancy , Ranging from 4 for lewly to 12

Complications

BPSd is assocaited With Hospotalizations and cardio vascislatrity on Family Care Givers-

Deterence and Patient Education

Deterence : Show to reduce Cognitive Decline, Pharmacological for hyerptension Patient Education : Home CAre giverr

Enhancing healcare team outcomes

Nurses And asssisant on front lines of BPSd -Physical And Recreations Social workers Can Suprot family care givers / clinical Psychologists Non Pharma Interventions.

Review Questions

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Explore BPSD (Behavioral and Psychological Symptoms of Dementia), its symptoms like hallucinations and delusions, and associated conditions such as vascular dementia. Understand diagnosis, management, and physical findings. Learn about reversible exacerbating factors and initial steps for acute onset.