1st February 2024

Delirium, Behavioural and Psychological Symptoms of Dementia (BPSD)

Delirium

Background

Delirium is derived from the Latin word ‘de lira’, meaning ‘out of the furrow’.

Delirium is a serious neuropsychiatric syndrome called an acute confusional state or acute brain failure common among medically unwell individuals. It is often misdiagnosed as a psychiatric illness, which can delay the diagnosis and management of the patient. The delay is mainly in offering the right medical intervention. It is a medical emergency.

Delirium is characterised by global impairments in attention and cognition. It is a common and serious condition that can be identified and treated well before it worsens.

Types

1. Hypoactive Delirium
2. Hyperactive Delirium
3. Mixed type of Delirium

DSM 5 Criteria- All the criteria to be met:

1. Disturbance in attention and awareness (reduced ability to direct, focus, sustain and shift attention)
2. The disturbance  develops acutely and fluctuates in severity
3. At least one additional disturbance in cognition (deficits in memory, orientation, language and communication, executive function, visuospatial-visuoperceptual, 
4. Disturbances cannot be explained by pre-existing dementia
5. Disturbances do not occur in the context of a severely reduced level of arousal or coma
6. Evidence of an underlying organic cause or causes (evidence from history, examination or investigations)

Epidemiology

Literature search goes back to the first century. This condition was defined as a state of altered consciousness, behavioural anomalies and fever. Subsequently, it encompassed intoxication and other conditions too.

In the 19th century, delirium was finally defined as a stereotypic manifestation of acute cerebral disturbance and referred to toxic and infective causes. After the 1950s, distinctive cerebral insufficiency or acute brain failure was identified.

• It is the commonest psychiatric presentation of a medical illness observed in admitted patients.
• It is the commonest psychiatric manifestation in medical and surgical patients
• 10-30% of the individuals in the general ward can manifest with delirium at some point of admission.
• The incidence can be as high as 80% among critically ill patients.
• In older individuals, the incidence can be as high as 30-60%
• The incidence in the community is comparatively lower, around 1-2%
• Rates are higher in post-surgical (hip surgery), ICU and palliative care patients. Evidence suggests that this can be of the order of 70-80%.
• Pre-existing dementia increases the risk of delirium by 5 fold
• Almost half of the cases are preventable

Risk factors

• Age is by far the commonest risk factor
• Serious medical conditions- malignancy, burns, dialysis
• Endocrinological abnormalities- hypo or hyperthyroidism and parathyroidism, Cushing’s and Addison’s syndrome
• Environmental changes and emotional distress
• Infections and inflammatory conditions, UTI, constipation
• Major surgery- Usually 2nd/3rd post-op day. Surgeries such as cardiotomy, hip surgery and transplantation have been noted to be risk factors
• Metabolic causes- Hypoglycaemia, hypo or hyperkalaemia, hypo or hypernatremia, acidosis and alkalosis, anaemia, hypoalbuminemia
• Medications- sedatives, hypnotics, steroids, polypharmacy, painkillers, anticholinergics, narcotics
• Nutritional- Anaemia, vitamin deficiencies
• Pain
• Pre-existing CNS lesions- Parkinson’s, stroke, dementia
• Sleep deprivation
• Substance abuse
• Systemic infections- Sepsis, peritonitis, etc.
• Shock
• Sensory deprivation 
• Traumatic causes
• In 30% of cases, there is no known cause

Pathophysiology

The aforementioned risk factors contribute to the exposure of the brain to hyperdopaminergic and hypocholinergic states and, therefore, lead to impaired functioning of the brain. 

Multiple pathogeneses have been hypothesised:

1. The permeability of the blood-brain barrier is increased in infections and inflammatory conditions
2. Reduced cerebral perfusion is an added factor in association with CNS conditions
3. Disruption of RAS- Reticular activating system
4. Hyperdopaminergic state due to excess dopamine release in reaction to oxidative stress
5. Hypomelatonin state and hyper norepinephrine can result in sleep-wake disturbances impacting circadian rhythm
6. Excess GABA activity and or reduced activity can be seen causing delirium
7. Cerebral metabolic inadequacy due to impaired glucose metabolism
8. Tissue destruction, infection and inflammation can cause excess cytokines
9. The functional connection between the dorsal anterior cingulate cortex and the suprachiasmatic nucleus is augmented here, while that with the posterior cingulate cortex, parahippocampal gyrus, cerebellum and thalamus is lessened. Likewise, functional connectivity between the dorsolateral prefrontal cortex and posterior cingulate cortex is amplified, while the connectivity is reduced with subcortical regions of the brain.

Clinical presentation

In general, features include:

• Patients appearing distressed and distracted 
• Patients being disorientated with poor awareness of time, place and person
• Disorganised thinking
• Inattention
• Mood swings
• Visual and auditory hallucinations
• Paranoid and persecutory delusions- especially fear of others plotting against or trying to hurt or harm them.
• Poor speech and conversation
• Inability to do things that have been done in the past (simple day-to-day activities)
• Altered sleep-wake cycle
• Inappropriate or unsafe behaviours (challenging behaviours)
• Emotional lability
• Loss of appetite

In addition to the above symptoms, the following features may be specific in the different types of delirium:

Hypoactive delirium

• Excess sleep/somnolence
• Reduced arousal and inability to stay focused when being awake
• Lethargic and mute
• Withdrawn
• Mistaken as depression as many of the symptoms could be suggestive of depressive illness
• Risk of delayed diagnosis and delayed management
• Very quiet and silent
• Poor eating and less mobile

Hyperactive delirium

• Increased agitation and restlessness
• Hypervigilance and increased anxiety
• Aggression, physical and verbal aggression
• Increased sympathetic activity (Increased heart rate and temperature, blood pressure)
• Nausea, diarrhoea
• Psychotic symptoms
• Challenging behaviour
• Resisting personal care

Mixed presentation

They will switch between hyper and hypo symptoms.

Differential diagnosis

• Dementia
• Depression
• Anxiety
• Thyroid problems
• Temporal lobe epilepsy
• Charles Bonnet Syndrome

Assessment

History

• Detailed history from the individual
• Collateral history from the relatives, carers and ward staff 
• Information in chronological order about situations or history that led to the present symptoms
• Details about substance misuse, medications- particularly CNS effects, new addition, discontinuations, changes in dose, overdosing

Mental State examination

The following should be assessed as part of the mental state examination:

• DSM-5/ ICD-11 criteria
• Appearance and behaviour, speech, mood and affect, thought form and content, perceptional abnormalities, insight
• Attention
• Memory

Examination

• Physical examination:
  • Vital signs
  • Hydration
  • Signs of infection
  • Systemic examination- CVS, Respiratory examination, Abdominal and Neurological examination
  • Head-to-toe examination 

• Cognitive assessment
  • AMTS- Abbreviated Mental State Score/ the Hodkinson Mental test- A score of 6 or less than 6 suggests dementia or delirium but needs further tests for confirmation
  • CAM- Confusion Assessment Method- The diagnosis of delirium needs both A and B with either C and/or D
    • Acute onset and fluctuating course
    • Inattention- Difficulty in focusing and easily distracted
    • Disorganised thinking- disorganised and incoherent. This could include rambling speech and unpredictable switching of subjects. Illogical flow of ideas and unclear thoughts
    • Altered level of consciousness- hyper-vigilant or drowsy, stuporous or comatose
• 4-AT Test- Rapid clinical test for delirium. It is scored from 0 to 2/4. A score of more than 4 is suggestive of Delirium. It is helpful in ED settings, care homes, emergency settings, etc. More details can be obtained from 4AT preview — 4AT – RAPID CLINICAL TEST FOR DELIRIUM (the4at.com)

Investigations

• Bloods – FBC, renal and liver function tests, vitamin B12/ folate, vitamin D, TFTs, blood glucose
• Blood cultures and urine cultures
• CXR to look for infection 
• EEG and lumbar puncture if required

Management

Generally, we follow a bio-psycho-social approach. Here, environmental and general measures take first place. Delirium will usually improve if a reason is identified and managed.

Non-pharmacological strategies

• A supportive and calm environment is the mainstay of management 
• Arranging hearing and visual aids if patient usually uses these
• Encouraging reorienting patient to their surroundings, the date, time and year. Reiterating the venue and the reason for admission.
• Arranging a 24-hour clock and calendar that can be visualised easily to support orientation
• Encouraging intake- both food and fluids
• Encouraging a good sleep routine
• Arranging a silent and corner room that is well-lit. The lighting should be natural during the day, with attenuated light at night to reduce misperceptions and illusions.
• Consistent care offered by the staff
• Avoid moving the patient to different wards or places
• Protecting the patient and others- safekeeping surroundings, removing dangerous objects, etc.
• Psychoeducation to the relatives to understand the illness and myths associated with the explanation of medications and non-medical treatment.
• Relatives can bring personal objects like pictures, blankets, books, and mugs that can help reorient the patient.
• Staff to maintain a calm and reassuring attitude towards the patients
• Encouraging walking and maintaining activity if feasible
• Avoid unnecessary interventions

Pharmacological measures

• Addressing the specific causes:
  • Infections> Antibiotics
  • Dehydration> Fluids
  • Urinary retention> Catheter if needed
  • Constipation> Laxatives
  • Pain> Painkillers
  • Medication changes or, recent addition or dose changes> May need to be rectified
  • Hypoglycemia, hypoxia, electrolyte imbalance> need correction

• Liaise with the Liaison Psychiatry for management of patients with challenging symptoms.
  • Antipsychotics: Haloperidol is licensed for delirium, but the evidence is very limited. There is a risk of side effects like Extrapyramidal side effects ( EPSE) and cardiac effects. Risperidone and Olanzapine are also given at the lowest doses, depending on the trust policy. The doses should be very low and, if needed, should be increased slowly. Antipsychotics can increase the risk of metabolic syndrome, weight gain, hyperlipidaemia and type 2 diabetes. They also carry a risk of stroke. 
  • Benzodiazepines (BZDs): Generally, these should be avoided. However, when antipsychotics are contraindicated, BZDs can be used. Small doses of Lorazepam can be considered based on trust guidelines. BZD can increase confusion, sedation and falls, as well as increase respiratory depression. Hence, the risks and benefits of treatment need to be carefully weighed. 
  • It is essential to monitor vitals every 30 minutes for 4 hours after giving an antipsychotic.
  • Covert medication can be considered in severe aggression
  • Medication needs to be reviewed regularly and discontinued when delirium resolves. 
  • An old age psychiatry specialist should be consulted if someone has dementia or cerebrovascular condition and is prescribed medication for delirium. 
  • If discharged with medication for delirium, the patient’s medication needs to be followed up with a discharging regime.

Social

• This has already been discussed as non-pharmacological approach. 
• Delirium can continue for a few months. Hence, continued vigilance is pertinent with regard to the environmental, sensory needs and pharmacological aspects.

Prognosis

The condition increases the current hospital stay and increases the risk of developing dementia in the future. Morbidity and mortality are both high. There is risk of various fatal complications such as aspiration pneumonia and respiratory failure, malnutrition and electrolyte imbalances, confusion and falls, frailty associated with mobility and reduced day-to-day functioning, long-term cognitive deficits, pressure ulcers and remaining bedridden. Hence, it is essential to identify the preventable causes and detect delirium earlier.

References

• NICE (2021). CKS Is Only Available in the UK. [online] NICE. Available at: https://cks.nice.org.uk/topics/delirium/diagnosis/assessment/
• Abdullah, H., Tan, S., Lee, S., Bin, H., Razak, A., Seet, R., Ying, H., Sethi, E. and Sim, E. (2018). Protocol for a single-centre prospective observational study of postoperative delirium following total joint arthroplasties among South East Asians. BMJ Open, [online] 8, p.19426. doi:https://doi.org/10.1136/bmjopen-2017-019426.
• Oxford Medical Education. (2015). Confusion Assessment Method (CAM). [online] Available at: https://oxfordmedicaleducation.com/geriatrics/cam/
• Abbreviated Mental Test Score. (n.d.). Available at: https://www.bgs.org.uk/sites/default/files/content/attachment/2018-07-05/abbreviated_mental_test_score.pdf
• Alzheimer’s Society (2017). Delirium. [online] Alzheimer’s Society. Available at: https://www.alzheimers.org.uk/get-support/daily-living/delirium
• ‌PsychDB. (2021). Delirium. [online] Available at: https://www.psychdb.com/cl/1-delirium#pathophysiology [Accessed 2 Apr. 2023].
• bcmj.org. (n.d.). Delirium in older adults: Diagnosis, prevention, and treatment | British Columbia Medical Journal. [online] Available at: https://bcmj.org/articles/delirium-older-adults-diagnosis-prevention-and-treatment#a1 [Accessed 2 Apr. 2023].Brown, T.M. (2002). ABC of psychological medicine: Delirium. BMJ, 325(7365), pp.644–647. doi:https://doi.org/10.1136/bmj.325.7365.644.
• Thom, R.P., Levy-Carrick, N.C., Bui, M. and Silbersweig, D. (2019). Delirium. American Journal of Psychiatry, [online] 176(10), pp.785–793. doi:https://doi.org/10.1176/appi.ajp.2018.18070893.
• Ramírez Echeverría, M. de L. and Paul, M. (2020). Delirium. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470399/
• HODKINSON, H.M. (1972). EVALUATION OF A MENTAL TEST SCORE FOR ASSESSMENT OF MENTAL IMPAIRMENT IN THE ELDERLY. Age and Ageing, 1(4), pp.233–238. doi:https://doi.org/10.1093/ageing/1.4.233.
• MSD Manual Professional Edition. (n.d.). Delirium – Neurologic Disorders. [online] Available at: https://www.msdmanuals.com/professional/neurologic-disorders/delirium-and-dementia/delirium#:~:text=Stress%20of%20any%20kind%20upregulates%20sympathetic%20tone%20and [Accessed 2 Apr. 2023].
• Marcantonio, E.R. (2005). Clinical management and prevention of delirium. Psychiatry, 4(1), pp.68–72. doi:https://doi.org/10.1383/psyt.4.1.68.58306.
• Bourne, R.S., Tahir, T.A., Borthwick, M. and Sampson, E.L. (2008). Drug treatment of delirium: Past, present and future. Journal of Psychosomatic Research, 65(3), pp.273–282. doi:https://doi.org/10.1016/j.jpsychores.2008.05.025.
• O’Malley, G., Leonard, M., Meagher, D. and O’Keeffe, S.T. (2008). The delirium experience: A review. Journal of Psychosomatic Research, 65(3), pp.223–228. doi:https://doi.org/10.1016/j.jpsychores.2008.05.017.
• Carter, J. and Rodda, J. (2013). Recognising and managing delirium. BMJ, p.f2398. doi:https://doi.org/10.1136/sbmj.f2398.
• www.youtube.com. (n.d.). Delirium Awareness Video (#icanpreventdelirium) | Creative Connection. [online] Available at: https://youtu.be/BPfZgBmcQB8 [Accessed 2 Apr. 2023].
• Lek Suthida (2016). Delirium. [online] Available at: https://www.slideshare.net/leksuthida/delirium-57370744 [Accessed 2 Apr. 2023].
• vihang tayde (2018). Delirium. [online] Available at: https://www.slideshare.net/vihangtayde/delirium-87193715 [Accessed 2 Apr. 2023].
• PsychDB. (2021). Delirium. [online] Available at: https://www.psychdb.com/cl/1-delirium#primer [Accessed 2 Apr. 2023].
• Neha Bhatt (2017). Delirium. [online] Available at: https://www.slideshare.net/NehaBhatt8/delirium-77294827 [Accessed 2 Apr. 2023].
• 4AT – RAPID CLINICAL TEST FOR DELIRIUM. (n.d.). 4AT – Rapid Clinical Test for Delirium Detection. [online] Available at: https://www.the4at.com/#:~:text=The%204AT%20is%20a%20simple%20and%20short%20%28%3C2 [Accessed 15 Apr. 2023].

Behavioural and Psychological Symptoms of Dementia (BPSD)

Background

BPSD- Behavioural and psychological symptoms of dementia are a very common presentation. This describes a range of challenging behaviours, psychological reactions and symptoms occurring due to the presence of dementia. It can be distressing to not only the individual with dementia but also their caregivers. 

It includes both non-cognitive and non-neurological features of dementia.

Epidemiology

It is so common that almost 8 to 9 out of 10 patients with dementia may experience BPSD. One third of patients with dementia live in a care home, and two-thirds of these people suffer from BPSD at any point in time. It is associated with excess disability and hospitalisation. This can increase financial costs.

Causes

As dementia progresses, these behavioural changes become obvious. There can be various reasons why someone could experience such changes:

• Worsening cognition
• Frustration about memory, confusion, language difficulties
• Disorientation to date and time can worsen behaviour
• Not being understood
• Not being in control of their life suddenly and not having the privilege of being with family and friends
• Unmet needs and inability to express their needs
• Physical health problems- very similar to causes mentioned above in Delirium
• Mental health problems- due to depression, psychosis
• Social needs- being bored and  altered day-to-day activities
• Reduced threshold to stress and easily distressed

Clinical presentation

• These are symptoms in addition to the core symptoms of dementia
• Symptoms present for at least 1 month 
• Symptoms are severe enough to cause disruption in patient’s and or in others’ function

Behavioural symptoms

• Anxiety- pacing, being on the go, fidgety, fear of being alone, Godot syndrome (repeatedly questioning), irritability and resisting care
• Agitation
  • Physical aggression- hitting, pinching, punching, biting, scratching, kicking, fighting, pushing and restless
  • Verbal aggression- screaming, anger outbursts, being bossy, making loud noises, repeated vocalisation, making irrelevant comments, cursing, arguing and complaining
• Altered circadian rhythm
  • Disturbed sleep
  • Day and night reversal
• Wandering
• Impulsive behaviour
• Poor insight and poor judgement
• Catastrophic reactions
  • Sudden excessive emotional response or physical behaviour
• Disinhibited behaviour
  • Socially inappropriate
  • Sexualised behaviour
  • Dressing inappropriately

Psychological symptoms

• Psychosis
  • Visual and auditory hallucinations
  • Delusions- paranoid and persecutory
  • No psychosis in the past usually
  • No other causes for psychotic symptoms
  • No criteria met regarding delirium
• Depression
  • Self-pity
  • Anhedonia
  • Psychomotor disturbances
  • Lack of initiative and motivation
  • Low mood and poor energy
  • Sleep disturbances
  • Withdrawn
  • Poor diet and self-care
  • Crying spells

Differential diagnosis

• Delirium
• Depression
• Medical illnesses and medications
• Environmental changes

Assessment/Investigations

Very similar to Delirium

BPSD scales are available. For example: CMAI- Cohen Mansfield Agitation inventory, NPI- Neuropsychiatric inventory

Management

Generally, we follow a bio-psycho-social approach. Here, environmental and general measures take first priority:

Non-pharmacological strategies

• Very similar strategies to those used in delirium
• Offer Reminiscent therapy
• Other therapies include- Music, aroma, pet, dance, touch, light therapy, etc.
• Maintaining ABC Behavioural charts

Pharmacological measures

• It is essential to differentiate delirium and BPSD
• Medications are usually for symptomatic control. They are always started at low doses, and increments are slow (See BNF or your trust guidelines for help with doses). Medications need regular review with the aim of stopping them as soon as safely possible
• Patient should be monitored for decline in cognitive functioning and for stroke, especially when on antipsychotics
• Medications to address specific triggers for the challenging symptoms:
  • Pain> Analgesia
  • Depression, anxiety and irritability>Antidepressants such as  SSRI, Mirtazapine, Trazodone
  • Lack of sleep>Zopiclone, Zolpidem ( Z-Drugs)
  • REM Sleep disorder>Clonazepam
• In patients with Alzheimer’s dementia, Vascular dementia or Frontotemporal dementia who present with depression or anxiety, we can consider SSRIs
• In patients with Alzheimer’s dementia, Vascular dementia and Frontotemporal dementia who present with psychotic symptoms or severe agitation and aggression, we can consider antipsychotics like Risperidone or Olanzapine
• In patients with Lewy Body and Parkinson’s dementia who present with depression or anxiety, we can consider SSRIs or Acetylcholinesterase inhibitors as second-line
• In patients with Lewy Body and Parkinson’s dementia who present with psychotic symptoms or severe agitation and aggression, we can consider Acetylcholinesterase inhibitors as the first-line option and Quetiapine as the second-line option
• Like in Delirium, Benzodiazepines should be avoided and used only if needed as an emergency

Social

Very similar to Delirium

Prognosis

Since BPSD is a very common condition, it is essential to identify it early and prevent it if possible. A thorough medical review should be carried out to identify physical health problems, which could be a triggering factor for BPSD. A review of medications and medication changes can also prevent BPSD. Identifying early warning signs and the antecedent situations for BPSD is also essential. 

No right or wrong treatment approach exists, but person-centred care is appropriate. Non-pharmacological approaches and social care are the first treatment choices; medications are offered if that does not work. Promoting positive activities and exercises and aiming for personalised activities are important parts of care in BPSD.

References

• Improving the care for older people Delirium toolkit THINK DELIRIUM. (n.d.). Available at: https://www.healthcareimprovementscotland.org/idoc.ashx?docid=49bc5fb4-196f-49ea-a375-52a988594b45&version=-1 [Accessed 3 Apr. 2023].
• www.alzheimers.org.uk. (n.d.). Restlessness and agitation in dementia | Alzheimer’s Society. [online] Available at: https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/symptoms/restlessness#content-start
• Nguyen, J., Ko, I., Martinez-Sosa, S. and Mizoguchi, R. (2021). Ward based management of behavioural and psychological symptoms of dementia. BMJ, p.n1779. doi:https://doi.org/10.1136/bmj.n1779.
• Murray, B., Shaw, H. and Macdonald, O. (2019). Guidelines for the management of Behavioural and Psychological Symptoms of Dementia (BPSD). [online] Available at: http://www.oxfordhealthformulary.nhs.uk/docs/OHFT%20BPSD%20Guideline%20May%202019.pdf
• PsychDB (2019). Behavioural and Psychological Symptoms of Dementia (BPSD). [online] PsychDB. Available at: https://www.psychdb.com/geri/dementia/1-bpsd
• Optimising treatment and care for people with behavioural and psychological symptoms of dementia. (n.d.). Available at: https://www.alzheimers.org.uk/sites/default/files/2018-08/Optimising%20treatment%20and%20care%20-%20best%20practice%20guide.pdf?downloadID=609
• Franchi, B. (2016). Pharmacological management of behavioural and psychological symptoms of dementia. Journal of Pharmacy Practice and Research, 46(3), pp.277–285. doi:https://doi.org/10.1002/jppr.1260.
• Feast, A., Orrell, M., Charlesworth, G., Melunsky, N., Poland, F. and Moniz-Cook, E. (2016). Behavioural and psychological symptoms in dementia and the challenges for family carers: Systematic review. British Journal of Psychiatry, [online] 208(5), pp.429–434. doi:https://doi.org/10.1192/bjp.bp.114.153684.
• Dr Sally Thomas, Clinical Director, CC&D Service, Cornwall Partnership NHS FT Dr Henry Cameron, Consultant in Old Age Psychiatry, CC&D, Cornwall Partnership NHS FT Dr Simon Vann Jones, Consultant in Old Age Psychiatry, CC&D, Cornwall Partnership NHS FT, 4th April 2023
• bpac.org.nz. (n.d.). Managing the behavioural and psychological symptoms of dementia – bpacnz. [online] Available at: https://bpac.org.nz/2020/bpsd.aspx
• Cummings, J.L., Mega, M., Gray, K., Rosenberg-Thompson, S., Carusi, D.A. and Gornbein, J. (1994). The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology, [online] 44(12), pp.2308–2308. doi:https://doi.org/10.1212/wnl.44.12.2308.
• Fauth, E.B. and Gibbons, A. (2013). Which behavioural and psychological symptoms of dementia are the most problematic? Variability by prevalence, intensity, distress ratings, and associations with caregiver depressive symptoms. International Journal of Geriatric Psychiatry, 29(3), pp.263–271. doi:https://doi.org/10.1002/gps.4002.
• Soyinka, A. and Lawley, D. (2007). Antipsychotic prescribing for behavioural and psychological symptoms of dementia. Psychiatric Bulletin, 31(5), pp.176–178. doi:https://doi.org/10.1192/pb.bp.106.010967.
• southwest.devonformularyguidance.nhs.uk. (n.d.). Management of behavioural and psychological symptoms of dementia (BPSD). [online] Available at: https://southwest.devonformularyguidance.nhs.uk/formulary/chapters/4.-central-nervous-system/bpsd [Accessed 2 Mar. 2023].