Managing Behavioral and Psychological Symptoms of Dementia (BPSD)

Dementia is an acquire brain syndrome characterised by a decline from a previous level of cognitive functioning with impairment in two or more cognitive domains (such as memory, executive functions, attention, language, social cognition and judgement, psychomotor speed, visuo-perceptual or visuospatial abilities). The impairment is not entirely attributable to normal aging and significantly affects patients daily activities.

Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms, represent a heterogeneous group of non-cognitive symptoms and behaviors occurring in subjects with dementia.

It is estimated that BPSD affect up to 90% of all dementia subjects over the course of their illness. BPSD includes emotional, perceptual, and behavioral disturbances that are similar to those seen in psychiatric disorders.

It may be clinically useful to classify them into five domains: cognitive/perceptual (delusions, hallucinations), motor (e.g., pacing, wandering, repetitive movements, physical aggression), verbal (e.g., yelling, calling out, repetitive speech, verbal aggression), emotional (e.g., euphoria, depression, apathy, anxiety, irritability), and vegetative (disturbances in sleep and appetite).

Etiology of BPSD is complex and multifactorial. Various biological, psychological and social or environmental factors contributes to the behavioural and psychological problems.

Management of BPSD

Medical Evaluation for contributing factors

Behavioural changes, specially if symptoms appear said suddenly, or a signal for a thorough medical evaluation. An examination may reveal other treatable causes such as medication side-effects, environmental changes, infection, exacerbation of chronic conditions, or loss of hearing or vision.

Non-pharmacological strategies

In the absence of treatable condition, non-pharmacological strategies are the first line to treat BPSD. Focus should be patient centered and caregiver centered. Psychoeducation and Coping strategy-based family carer therapy to be provided to caregivers of individuals with dementia, it plays an important role in reducing caregiver stress and coping with challenging behaviours in dementia patients.

Caregiver training typically focuses on understanding behavioral disturbances as responses to discomfort, unmet needs, or attempts to communicate; creating soothing environments with optimal levels of stimulation; and responding to patients in ways that de-escalate problematic behaviors (e.g., distraction, giving patients clear instructions and simple choices, not rewarding the behaviors).

Other non-pharmacological approaches:

• Cognitive/emotion-oriented interventions (reminiscence therapy, simulated presence therapy, validation therapy);
• Sensory stimulation interventions (acupuncture, aromatherapy, light therapy, massage/touch, music therapy, Snoezelen multisensory stimulation, transcutaneous electrical nerve stimulation);
• Behavior management techniques;
• Other psychosocial interventions such as animal-assisted therapy and exercise.

Pharmacologic Interventions

If non-pharmacological approaches are insufficient or fail, and the patient has severe symptoms or is at risk to harm him or herself or others consider medications. Antipsychotics: Second-generation antipsychotics (primarily risperidone, olanzapine, quetiapine, and aripiprazole) are the mainstay of treatment for agitation and aggression. Antidepressants, anticonvulsants and mood stabilisers have been used to treat other BPSD symptoms. Cognitive enhancers for managing dementia.

Dr. Ekta Yadav
Dr. Kavita P Gadadavar
Senior resident
Dept. of Psychiatry
KLE hospital