1st February 2024

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.