Behavioral and Psychological Symptoms of Dementia: Understanding and Managing BPSD

Introduction

Dementia is a debilitating condition that affects cognitive function, behavior, and emotional well-being. One of the most challenging aspects of dementia is dealing with behavioral and psychological symptoms that occur in more than 90% of individuals with dementia. These symptoms are referred to as behavioral and psychological symptoms of dementia (BPSD). BPSD is associated with a faster decline in cognition and function among individuals with dementia, which often results in the placement of those with dementia in care facilities.

Types of BPSD

BPSD is a constellation of symptoms and behaviors, and the specific symptoms can vary depending on the type of dementia. Apathy is the most common BPSD seen among individuals with Alzheimer’s disease (AD), whereas depression is the most common BPSD among individuals with vascular dementia (VD). Anxiety is the most common BPSD noted in individuals with dementia with Lewy bodies (DLB), and agitation and aggression are the most common BPSD identified among individuals with frontotemporal dementia (FTD).

The Impact of BPSD

BPSD contributes directly and indirectly to one-third of the cost of caring for individuals with dementia because of the greater utilization of health resources and services. Additionally, BPSD adds significantly to increased distress and depression among caregivers of individuals with dementia. Finally, BPSD contributes significantly to the greater rates of morbidity and mortality among those with dementia.

Treatments for BPSD

Thankfully, evidence indicates efficacy for both nonpharmacological and pharmacological treatments for BPSD. The use of pharmacotherapy is usually reserved for those who have not responded adequately to nonpharmacological treatments. Nonpharmacological interventions are the recommended first-line treatment for BPSD.

Nonpharmacological Interventions

Nonpharmacological treatments include a range of interventions such as behavioral therapy, sensory stimulation, and psychosocial support. Evidence from a meta-analysis by Trinh et al. indicates that individuals with BPSD who received acetylcholinesterase inhibitors did better on the Neuropsychiatric Inventory (NPI) scale by 1.72 points, compared with individuals who received a placebo, indicating a small but statistically significant benefit. Another meta-analysis found that individuals with BPSD who received memantine did better by 1.99 points on the NPI scale when compared with people receiving a placebo.

A meta-analysis by Seitz et al. found that individuals with BPSD who received sertraline and fluoxetine did better than those individuals who received a placebo on the Cohen Mansfield Agitation Inventory (CMAI) (mean difference (MD)=-0.89, P<0.001). Another meta-analysis by Bhaji et al. indicated benefits for cannabinoids on the CMAI (SMD = −0.80), the NPI total score (SMD=−0.61), the neuropsychiatric inventory-nursing home (NPI-NH)-Agitation/Aggression sub-score (SMD=−0.61), and on nocturnal motor activity (SMD=−1.05) among individuals with BPSD. A meta-analysis by Vacas et al. found benefits for repetitive transcranial magnetic stimulation (rTMS) among individuals with BPSD (overall effect=−0.58, P=0.01).

The Role of Antipsychotics

Antipsychotics are sometimes used to treat BPSD when nonpharmacological interventions are inadequate. In a meta-analysis by Yunusa et al., aripiprazole demonstrated benefits among individuals with BPSD compared with placebo on the NPI (SMD=−0.17), the Brief Psychiatric Rating Scale (BPRS) (SMD=-0.20), and on the CMAI (SMD=-0.30). The investigators also found benefits for quetiapine on the BPRS (SMD=−0.24) and risperidone on the CMAI (SMD=-0.26), when compared with placebo. However, the US Food and Drug Administration (FDA) has a boxed warning for increased risk of death for both atypical and typical antipsychotic medications when they are used among older individuals with dementia.

Yunusa et al. found that the odds of mortality were higher for various antipsychotics, including aripiprazole, brexpiprazole, olanzapine, quetiapine, and risperidone when compared with placebo. The investigators also noted that the use of risperidone and olanzapine increased the odds of cerebrovascular events compared with placebo.

Conclusion

BPSD is a challenging aspect of dementia care, but there are effective treatments available, including nonpharmacological interventions such as behavioral therapy and pharmacotherapy such as antipsychotics. It’s crucial to work with a healthcare provider to develop an individualized treatment plan that considers the risks and benefits of each intervention. With proper care and management, individuals with dementia and their caregivers can experience improved quality of life.

Originally Post From https://www.psychiatrictimes.com/view/treatment-options-for-the-management-of-behavioral-and-psychological-symptoms-of-dementia

Managing the Behavioral and Psychological Symptoms of Dementia: Treatment Options You Need to Know