1. Dementia – managing behavioural and psychological symptoms
Dr. Jonathan Hare
Consultant Old Age Psychiatrist
Barnet, Enfield & Haringey Mental Health Trust
Dr Robert Tobiansky

2. Dementia
A syndrome due to disease of the brain usually of a chronic or progressive nature
Multiple disturbances of higher cortical function
Global impairment: intellect, memory, personality
Changes in emotional control, social behaviour, motivation
In clear consciousness
Decline in usual functional abilities

3. Dementia Many causes but commonest are: Alzheimer’s Disease
Vascular Dementia
Lewy Body Dementia
Alcohol related dementia
Frontotemporal dementia

6. Dementia: general signs & symptoms
Early stages: memory impairment, loss of planning, judgement, difficulty with administrative tasks etc
intermediate impaired basic ADL can’t learn new information, increasing disorientation time & place
increased risk of falls and accidents due to confusion and poor judgment

7. Dementia: signs & symptoms
severe dementia: no ADL skills, totally dependent for feeding, toileting, & mobilising. Severe global cognitive impairment
risk of malnutrition and aspiration
poor mobility & malnutrition increases risk of pressure sores
Seizures, dehydration, malnutrition, aspiration, pressure sores
death from infection (resp., skin, UTI etc)

8. Dementia: signs & symptoms
Behavioural problems (BPSD):
Persecutory delusions, suspiciousness in c. 25%
wandering, aggression, agitation
Depressive symptoms in c. 60%
Depression in c. 25%

9. Delirium: DSM 4 criteria
Disturbance of consciousness with reduced ability to focus, sustain or shift attention
Change in cognitive function not due to pre-existing or evolving dementia
Development over short period of time – usually hours or days & tendency to fluctuate during course of day

10. Delirium: causes Infection
Drugs (prescribed & illicit, intoxication or withdrawal)
Organ failure (cardiac, resp., hepatic, renal)
Electrolyte disturbance (dehyd. Na/Ca/K)
Endocrine & metabolic – thyroid, glucose
CNS- CVA, subdural, SOL
Nutritional – thiamine deficiency
Malignancy
Hypothermia

11. Delirium: management Clarify history
Assessment of physical & mental state
Identify & treat underlying cause
May need to treat neuropsychiatric symptoms with modest doses of sedatives or antipsychotics
Well-lit, quiet room, address sensory impairment

12. Levels of evidence Metanalysis Randomised placebo controlled trials
Other studies
Expert opinion,
National guidance, local protocols, expert opinion etc

13. BPSD
Behavioural and Psychological Symptoms in Dementia

14. BPSD symptoms include:
Agitation
Aggression
Repetitive vocalisations
Sexual disinhibition
Wandering
Shadowing
Depression
Anxiety
Apathy
Delusions
Hallucinations
Irritability
Restlessness & overactivity

15. BPSD Very common in people with dementia
Almost all will have at least one symptom at some point in illness
Distress to patient & carers
Associated with increased institutionalisation
Faster rate of decline
Increased mortality
Increased stress for care staff

16. NICE guidance CG42
assess PWD who develop behaviour that challenges
the person's physical health
depression
possible undetected pain or discomfort
side effects of medication
individual biography, including religious, spiritual & cultural
psychosocial factors
physical environmental factors
Individually tailored care plans, recorded & reviewed regularly
Approaches that may be considered include:
aromatherapy
multisensory stimulation
therapeutic use of music and/or dancing
animal-assisted therapy.

17. Aetiology of BPSD (after Brodarty)
Biological
Psychosocial
Environmental

18. Biological potential causes
Frontal pathology – disinhibition, depression
Basal ganglia lesions-delusions
Temporal lobe pathology – delusions, hallucinations
Locus coeruleus – psychosis, depression
Previous / current psychiatric disorder:
depression / anxiety / psychosis

19. Biological causes Acute medical illness eg UTI, RTI causing delirium
Medication
Pain syndromes
Constipation
Urinary retention
Sensory impairment
Basic needs – tiredness, hunger, thirst

20. Psychological causes Previous psychiatric illness
Premorbid personality- no meaningful correlations
Frustration
fear
Interpersonal / reaction of others

21. Environmental factors
Overstimulation
Understimulation (boredom)
Overcrowding
Inconsistent care givers, high staff changes
Provocation by others

22. “Something must be done”
Who’s problem is it?
What is the behaviour?
When does it occur?
Where does it occur?
Try to understand the behaviour, why is this person presenting like this at this time?
Intervene if behaviour results in distress or risk to patient or others

23. Before intervening Clarify the nature of the problem
Document /keep ABC chart of behaviour
Confirm most difficult challenging behaviour
Are there triggers?
Exclude non-dementia causes
treat medical disorders & any causes of disability (mobility, vision, hearing etc )
NB PAIN!

24. Environment Modify environment (nidotherapy) Adequate space
Privacy available
Personalised space
Avoid over / under stimulation
Lighting, colours, furnishing, architecture
Size of unit
Mix of residents
staff

25. Possible Interventions
Bright light therapy- weak evidence
Aromatherapy (lemon balm, lavender) moderate evidence, cochrane review
Snoezelen:multisensory stimulation (modest evidence)
Music therapy
Person centred / dementia care mapping
My life package
Cognitive stimulation therapy

26. Interpersonal Staff education, support & training
Dementia care mapping
Person centred care (Kitwood) individualised care planning, fairly good evidence can reduce BPSD
Psychoeducation for carers
Behaviour management techniques

27. Therapeutic approaches
Reminiscence groups
Relaxation training
Behavioural management techniques

28. Medication
Medication for Behavioural & Psychological Symptoms in Dementia (BPSD)

29. Medication: Antidementia drugs
-cholinesterase inhibitors:
donepezil (Aricept)
rivastigmine (exelon)
galantamine (reminyl)
-Memantine (Ebixa)

30. Licenced drugs
Risperidone is the only licensed drug for the treatment of BPSD (aggression)
Antidementia drugs are licensed for treatment of cognition not behaviour in restricted severity groups
Cholinesterase inhibitors for mild to moderate AD
Rivastigmine for mild to moderate Parkinson’s Disease Dementia
Memantine for moderate to severe AD

31. Other medication for BPSD
Antidepressants
Anxiolytics
Hypnotics
Antipsychotics
Anticonvulsants

32. Cholinesterase inhibitors for BPSD
Systematic review & meta-analysis
Statistically significant vs placebo
Modest clinical benefit
Biggest response on individual symptoms, apathy, hallucinations,

33. Memantine for BPSD
Several RCTs vs placebo (eg Reisberg,et al; Tariot et al; Van Dyck et al; Gauthier et al)
Small effect aggression, agitation

34. Depression in dementia: Cochrane review
Antidepressant
Dose Study N Duration Outcomes
Sertraline
25-150mg Lyketos et al wks Positive
Clomipramine
25-100mg Petracca et al wks Positive
Imipramine
mg Reifler et al wks n.s.

35. Antidepressants in dementia
Study of Antidepressants for Depression in Dementia (SADD) study: Banerjee et al Lancet 2011
Mirtazapine & sertraline vs placebo
No significant benefits

36. CATIE-AD study Citalopram effects on BPSD Siddique et al 2009
Trend reduced irritability & apathy
Reduced hallucinations

37. Antidepressants in dementia: conclusion
Modest evidence efficacy
May benefit agitation

38. Antipsychotics in dementia
RCT evidence:
Haloperidol
Risperidone
Quetiapine
Olanzapine
Aripiprazole

39. CATIE-AD: 42 sites, 421 pts randomised to olanzapine, quetiapine, risperidone, placebo

40. Antipsychotics in dementia
Meta-analysis evidence: medium effect size
Benefit for severe aggression, delusions

41. Antipsychotics in dementia
2-3 x increased risk cerebrovascular adverse events
1-2% increased risk death

42. Defensible prescribing of antipsychotics in Dementia
Consider non-pharmacological alternatives
Address vascular risk factors
Consent / capacity / best interests
Discuss risks & benefits with patients or carers
Identify target symptoms (psychosis, hostility, aggression)
Choose effective drug & dose
Choose time-frame during which to assess benefits (discontinue if no evidence benefit or if harm)
review need & aim to withdraw in c 3/12 if possible

43. Doses of antipsychotics start range
Risperidone mg to 2mg/day
Olanzapine mg mg /day
Quetiapine mg mg
Aripiprazole mg mg

44. Anticonvulsants in dementia
Review of RCTs
Weak to modest evidence carbamazepine further trials needed
Poor evidence / negative for valproate mostly no significant difference
Adverse events more frequent in treatment groups

45. Benzodiazepines RCTs: Benzos reduce agitation
Adverse effects: falls, sedation, worsen cognition

46. Using medication in BPSD
Pharmacotherapy can be effective for BPSD
First step: identify target symptoms
Correct reversible factors
Try environmental & psychological approaches first unless high risk of harm to self / others
Use medication carefully, “start low go slow”
Review treatment

47. Thank you