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Behavioral and psychological symptoms of dementia
Background
Overview
Definition
BPSD is a heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors occurring in people with dementia of any etiology.
1
Pathophysiology
BPSD are caused due to a complex interplay of psychological, social, and biological factors including neurochemical, neuropathological and genetic factors.
2
Disease course
The complex interaction of psychosocial and biological factors results in BPSD, which have clinical manifestations of agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. Disease progression is associated with poor QoL, distress among patients and caregivers, long-term hospitalizations, medication misue,a nd increased health-care costs.
2
Prognosis and risk of recurrence
Moderate and severe BPSD are associated with an increased risk of mortality with HR 1.31 (95% CI, 1.08-1.60) and 1.74 (95% CI 1.44-2.12), respectively.
3
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of behavioral and psychological symptoms of dementia are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2023), the Canadian Coalition for Seniors' Mental Health (CCSMH 2024), the European Academy of Neurology (EAN 2020), the Danish Health Authority (DHA 2019), the College of Family ...
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Diagnostic investigations
Initial assessment: as per CCSMH 2024 guidelines, review the underlying etiology of dementia, the stage of dementia (mild, moderate, advanced), and the specific BPSD of concern, including the frequency, duration, severity, and any associated risks when assessing BPSD.
E
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Assessment tools (agitation)
Assessment tools (psychotic symptoms)
Assessment tools (depression)
Assessment tools (anxiety)
Assessment tools (sexual expressions)
Medical management
General principles: as per CCSMH 2024 guidelines, ensure interdisciplinary approaches to dementia care incorporating healthcare provider education on BPSD, structured approaches to assessment, individualized care plans, and personalized meaningful activities for the management of agitation in patients with dementia.
B
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Management of cerebrovascular factors
Discontinuation of opioids
Antipsychotics (indications)
Antipsychotics (choice of agent and dosage)
Antipsychotics (tapering and discontinuation)
Antidepressants
Benzodiazepines
Anticonvulsants
Cannabinoids
Cholinesterase inhibitors
Other agents
Nonpharmacologic interventions
Physical activity
As per CCSMH 2024 guidelines:
Advise physical exercise for the management of agitation in patients with dementia.
B
Advise physical exercise for the management of depressive symptoms in patients with dementia in community and long-term care settings.
B
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Psychosocial interventions
Music therapy
Companion pets
Use of restraints
Alternative and complementary medicine
Therapeutic procedures
Preventative measures
Primary prevention
As per DHA 2019 guidelines:
Use person-centered care in the treatment of patients with dementia to prevent behavioral and psychological symptoms.
B
Consider offering the following to prevent behavioral and psychological symptoms in patients with dementia:
supervised fitness training
sleep hygiene in case of sleep disorders
reminiscence therapy
psychoeducation (at least 3 sessions) to relatives living together with patients with dementia
C
Follow-up and surveillance
Assessment of treatment response
As per CCSMH 2024 guidelines:
Assess the effectiveness of the treatment plan for BPSD routinely and evaluate the plan to consider adjusting, changing, or discontinuing strategies as appropriate.
E
Consider discontinuing pharmacological treatment for agitation in dementia if it is ineffective after 8 weeks of treatment, including at least 2 weeks at a therapeutic dose.
C