1st February 2024

Behavioural and Pyschological 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].