Transcript Behavioural and Psychological Symptoms of Dementia (BPSD)

Behavioural and Psychological
Symptoms of Dementia
(BPSD)
Dr Manjula Atmakur
06/09/2011
Aim
Understand BPSD
Causes for BPSD
management
Definition of the BPSD:
Defined as:
Symptoms of disturbed perception,
thought content, mood or behaviour
that frequently occur in patients with
dementia. (Finkel & Burns, 1999)
Prevalence of BPSD
Approximately 83% of demented patients
demonstrate psychopathology.
64% of nursing home patients have
significant behavioural problems.
The most common BPSD resulting in
institutionalization are paranoia and
aggressive behaviour.
Delusion
60%
Affective symptoms
40%
Anxiety
35%
Verbal outburst
20%
Hallucination
20%
Aggression
13%
Clusters of BPSD
Mood disorders
depression,
anxiety, and
apathy/indifference
Psychotic
delusions and
hallucinations
Aberrant motor
behaviours
pacing,
wandering,
purposeless behaviours
Inappropriate
behaviour
agitation,
disinhibition,
euphoria
Aetiology
 Genetic (receptor polymorphism),
 Neurobiological aspects (neurochemical,
neuropathology),
 Psychological aspects (e.g.,premorbid
personality, response to stress) and
 Social aspects (e.g., environmental change and
caregiver factors).
Genetic
receptor polymorphism of subtypes of the
serotonin receptor associated with a
higher degree of aggressive and agitated
behaviour in patients with dementia
(Sukonick et al.2001)
Dopamine receptor related to psychosis
in Alzheimer’s disease (Sweet et al. 1998).
Neurotransmitter changes in dementia
 acetylcholine
 Dopamine
 Norepinephrine
 Serotonin
 Glutamate.
The significant decrease in cholinergic
activity may result in a relative increase in
monoaminergic activities, leading to hypo
manic or manic symptoms, and behaviour
that includes delusions, hallucinations and
physical aggression (Folstein, 1997).
Dopamine
 Levels of the dopamine and norepinephrine are
decreased in discrete areas of the brains of AD patients.
Approximately 25% of patients with AD have
parkinsonian symptoms, are associated with dopamine
deficiencies.
 Dopamine also plays a role in cognitive function, such
as working memory.
Aggressive behaviour may, like psychosis, be related to the
dopaminergic system. Demented patients with
aggression improve in behaviour when treated with
dopamine-blocking agents (Schneider et al.1990).
Dementia-related changes in the
norepinephrine system
Reduced norepinephrine levels are
associated with higher rates of depressive
symptoms or major depressive disorder in
patients with AD.
Higher levels of norepinephrine have been
found in the substantia nigra of patients
with AD and psychotic symptoms
(Zubenko et al., 1991).
Dementia-related changes in the
serotonin system
BPSD may be due to abnormalities in the
serotonergic system, which may result in
the following:
 depressed mood
 anxiety
 agitation
 restlessness
 aggressiveness
Dementia-related changes in glutamate
concentrations
The imbalance between the glutamate and
dopaminergic systems may lead to
dysfunction in the cortical neostriatalthalamic circuit, which may result in
psychotic symptoms.
Neuropatholoy Neurochemisty
Psychosis
↑plaques in prosubiculum
↑tangles in frontal cortex
↓density in limbic structures
↓density in ocular pathways
↓ serotonin in prosubiculum
↑ norepinephrine in substantia
nigra
Depression
↓ density in locus coeruleus
↓ density in substantia nigra
↓ density in all areas
↑ ventricle size
↓ density in raphe nucleus
↓ norepinephrine in neocortex
↑ dopamine in prosubiculum
↑ monoamine oxidase in all areas
↓ somatostatin in spinal fluid
Sleep
disturbances
↓ density in brainstem
Personality
changes
↓ density in nucleus basalis of
Meynert
↓ acetylchloride in frontal cortex
Personality/psychological contributors
to BPSD
results are mixed about whether an
individual’s premorbid personality has a
role in the development of BPSD
Patients who have shown suspicious,
aggressive or controlling behaviours prior
to the onset of dementia are more likely to
subsequently develop BPSD.
Environmental and social contributors
to BPSD
Patients with dementia are sensitive to
change in their social environment.
Cognitively impaired people are often
more susceptible to the effects of stressful
life events.
Caregiver distress and poor interpersonal
interactions between the patient and
caregiver can exacerbate BPSD.
Management
Non pharmacological
Pharmacological
Non pharmacological
 Non-pharmacological interventions are usually
first-line in dealing with milder behavioural and
psychological symptoms of dementia (BPSD).
 Symptoms that are most responsive to nonpharmacological interventions (Teri et al., 2000;
Teri et al., 1997) include:
– depression/apathy
– wandering/pacing
– repetitive questioning/mannerisms.
The ideal environment for a patient with
dementia is one that is non-stressful,
constant and familiar.
For patients with dementia, reality
orientation and music therapies have the
strongest research base (Spector et al.,
2000a; Woods, 2002),
A general approach to behavioral
interventions includes:
Identify the target BPSD
Gather information on the BPSD
Identify the triggers or consequential
events of a specific symptom
Set realistic goals and making plans
Encourage caregivers to reward
themselves and others for achieving goals
Continually evaluate and modify plans.
Pharmacological intervention
 Before deciding whether to treat BPSD with
medication, the following questions must be
addressed:
 Does the particular symptom or behaviour
warrant drug treatment, and why?
 Is this symptom or behaviour drug-responsive?
 Which category of medication is most suitable
for this symptom or behaviour?
 What are the predictable and potential side
effects of a particular drug treatment?
 How long should the treatment be continued?
People with dementia should receive
antipsychotic medication only when they
really need it. To achieve this, there is a
need for clear, realistic but ambitious goals
to be agreed for the reduction of the use of
antipsychotics for people with dementia.
Antipsychotic report
 Reducing the use of antipsychotic drugs for people with dementia
 People with dementia should receive antipsychotic medication only
when they really need it
 Risperidone-only licenced medication for aggression for short duration
 This guidance makes clear that people with dementia should only be
offered anti-psychotics if they are severely distressed or there is an
immediate risk of harm to the person or others
 There will occasions when the use of drugs will be necessary and in the
best interests of the person involved.
THANK YOU