1. Behavioural and Psychological Symptoms of Dementia Non-pharmacological and pharmacological approaches Dr Joy Ratcliffe, Consultant Psychiatrist Dr Julie Colville, Clinical Psychologist Lorraine Smith, Advanced Practitioner Manchester Mental Health and Social Care Trust & CMFT

2. BPSD  What is it?  Heterogeneous group non- cognitive behaviours  Not a diagnostic category – but very important  Think as a list of disturbed behaviours e.g.  Wandering  Agitation  Sexually disinhibited behaviours  Aggression  Paranoia/suspicion  Eliciting psychological/psychiatric problems e.g. depression, anxiety, delusional ideas/psychosis  All adds to risk

3. BPSD  Behavioural and psychological symptoms of dementia (BPSD) are common  They can be problematic in clinical practice and can form a significant part of the day-to-day work of primary care teams, later life psychiatry teams. CMHTs, inpatient and community settings.  We need to improve recognition and management of BPSD  Improved management can have a positive impact on the quality of life of our patients and carers both at home and in nursing/residential setting s  Positive management may also delay 24hr care

4. BPSD - Prevalence  Vary widely  Approx 2/3rds will experience BPSD at any one time  Approx 1/3 in the ‘clinically significant ‘range  Can rise to 80% in care homes  20% for BPSD in Alzheimer’s disease  BPSD tends to fluctuate with psycho-motor agitation most common and persistent

5. BPSD - Impact  BPSD rather than cognitive features are the major causes of care giving burden  Paranoia, aggression, disturbed sleep- wake cycles important drivers for 24hr care  BPSD also associated with worse outcome and illness progression  Adds significantly to direct and indirect care costs

6. Multiple Factors that influence Behaviour

7. Non Pharmacological management of BPSD –  Must be ‘collaborative’ -  Needs thorough Assessment - multiple factors  Need nursing home staff to input into assessment e.g. what do they know about their client?  Need staff e.g. Nursing Home to play key part e.g. ABCs - helps identify factors such as over/under stimulation, pain etc  Need staff to implement and monitor plans  Care Staff do need training in dementia  Need medical staff to ensure physical problems optimally treated e.g. infection, pain

8. Non Pharmacological management of BPSD  Understanding client’s history, lifestyle, culture and preferences, including their likes, dislikes, hobbies and interests.  Providing opportunities for the person to have conversations with other people.  Ensuring the person has the chance to try new things or take part in activities they enjoy.  Environmental factors-signage, lighting, photographs.  Reminiscence therapy.

9. Shared Care  Shared care plans to enhance communication and collaboration.  Discuss shared care plan.

10. Principle of Behaviour Management - Observing and Describing  What is happening  When does it happen  How often does it happen  Who is there when it’s happening  What is communication like  Why do you think it is happening  Any other observations

11. P rinciples of Behaviour Management - Contingencies  What are we targeting:  Frequency/ severity  High frequency/ low severity (lower consequences)  Low frequency/high severity (higher consequences)  High frequency/High severity (highest consequences)  What are ‘contingencies? e.g. positive and negative reinforcement

12. Biological Management Treat underlying cause Psychotropics? Severity Risk Distress Medical comorbidity / other meds esp vascular risks Capacity Views carers

13. Assessment  Delirium (caution not to miss hypoactive)?  PINCH ME (pain, infection, nutrition, constipation, hydration, medications, environment)  PAIN (physical / pain, activity related, iatrogenic, noise / environment)

14.  START LOW GO SLOW  Review target symptoms and adverse effects  How long to treat for  Gradual withdrawal  Licensed?

15. Psychosis- risperidone (0.25-0.5mg bd), olanzapine (2.5- 10mg), quetiapine (25-150mg) amisulpiride, aripiprazole, zuclopethixol Aggression- as above, trazadone, clomethiazole Agitation / anxiety- as above, citalopram, mirtazepine, memantine (AD), pregabalin Depression- sertraline, citalopram, mirtazepine Mania- valproate, lithium, antipsychotics Apathy- sertraline, citalopram, cholinesterase inhibitor (D, R, G) Sleep- temazapam, zopiclone, melantonin

16. Lewy Body Dementia (LBD)  CAUTION WITH ANTIPSYCHOTICS- quetiapine, aripiprazole, clozapine  1 st choice cholinesterase inhibitors  Clonazepam for REM sleep disorders

17. Vascular Dementia (VD)  Cholineterase inhibitors and memantine not licensed but majority of cases mixed AD / VD

18. Cholinesterase Inhibitors  Bradycardia  Prolonged QTC  LBBB  Gastric bleeding risk (pmhx, aspirin, NSAIDS, warfarin)  COPD / asthma  Epilepsy

19. Antipsychotics  ECG, QTC, other changes  Vascular risks  Increase cognitive impairment

20. Antidepressants  Sedation  GI bleeding  Na  Falls (inc SSRIs)  Citalopram –QTC, max dose 20mg

21. Anticonvulsants  Limited evidence  Adverse effects

22. Case Example  Case example  75, female, vascular dementia, 24 hr care for 12 months  Complaints from care staff  agitation  ‘breathless’ hyperventilating,  ‘attention seeking’ – calling every 5 mins  Saying pain (but where?)  toileting – incontinent faeces  falls, (needing extra monitoring)

23. Case Example  PERSONAL – lived alone many years – over stimulated  - remove to quieter environment  DEMENTIA – vascular with periods disorientation unable to express distress (language)  - try and reorientation/reassurance spend time with

24. Case Example  PHYSICAL – incontinence = ‘overflow’ compacted, meds 2 x laxatives and codeine (opposite actions?), pain (unable to express)  - Elimination of acute physical illness as triggers for BPSD. Reviewed with Advanced Practitioner - GP to check pain and review meds,  FALLS – interaction meds Trazadone and codeine, over –sedated  - meds review, Falls Team, Physio, frame

25. Case Example  PSYCHOLOGICAL – fear of falling exacerbated by previous falls, highly anxious (premorbidly – calling ambulance, GP, police etc)  Ongoing assessment by Psychology, anxiety still prominent  Linked to disorientation and/or premorbid anxiety  Activity/distraction, optimal?  Co pharmacological treatments – optimally treated?