Dementia: Behavioural and Psychological Symptoms
This Clinical Information Sheet (CIS) has been developed to assist RACF staff, medical practitioners and relevant professionals involved in the management of residential aged care patients with behavioural and psychological symptoms of dementia (BPSD). The diagnosis, assessment and management of dementia is beyond the scope of this Clinical Information Sheet. This sheet is intended to inform the management of behavioural and psychological symptoms in residents who have already been diagnosed with dementia.
This CIS covers:
About Behavioural and Psychological Symptoms of Dementia (BPSD); Assessment; Management; Non-pharmacological strategies; Medications; and Sources of Information Reference Cards:
The Neuropsychiatric Inventory Questionnaire
Cohen Mansfield Agitation Inventory
Behaviour Observation Chart
Sleep Assessment
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and Advance Care Plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Behavioural and Psychological Symptoms of Dementia (BPSD)
In Australia it is estimated that 5-10% of older adults have Alzheimer’s disease, although the incidence rate increases significantly with age. In adults aged over 85 years, annual incidence of dementia is 10-20%, increasing to over 30% in those aged over 90 years [1-3].
‘Behavioural and psychological symptoms of dementia’ (BPSD) is a term used to describe a range of symptoms that are associated with disturbed perception, thought content, behaviour or mood related to the presence of dementia [1-3].
The majority of residents with dementia (90%) will exhibit at least one behavioural or psychological symptom of dementia throughout the disease’s progression [3], and 31% will experience severe BPSD [4]. Age-related changes to the sleep-wake cycle are more pronounced in older adults with dementia, meaning many will experience sleep disturbances. Behaviours such as night-time wandering, night restlessness and insomnia and daytime napping are commonly displayed as a part of BPSD [5].
Dementia in older adults, presents caregivers with many challenges. Research suggests that challenging behaviours associated with dementia are poorly managed in RACFs. A recent Australian investigation identified that staff had difficulty managing aggression (in 70% of RACFs), wandering (55% RACFs), verbal and physical intrusiveness (18%), harmful behaviour (14%) and socially inappropriate behaviours (12%) [6]. The consequences of poor management of BPSD include increased caregiver stress, decreased resident and caregiver quality of life, increased financial costs of care and, often an increase in the dependency of the resident with dementia [2].
Specific psychological and behavioural symptoms vary depending upon the type and stage of dementia [1, 2]. Residents with Alzheimer’s disease commonly experience paranoia, hallucinations and verbally disruptive behaviours. Aggressive behaviour is more commonly observed in those with Lewy Body dementia, whilst vascular dementia patients are more susceptible to behaviours related to emotional instability [1, 2, 6]. Signs and symptoms effecting the resident’s mood are more likely to occur in early stages of dementia. Agitated and psychotic symptoms are more common in mid- stage dementia and decrease as the disease progresses. Wandering generally emerges in early stage dementia and persist longer than other symptoms [4].
Psychological symptoms
Psychological symptoms commonly displayed by residents with dementia are outlined in Table One.
Table One: Incidence of psychological symptoms in residents with dementia [1, 2, 4]
|
Behaviour
|
Incidence
|
|
Anxiety
|
Up to 80%
|
|
Depression
|
10-50%
|
|
Hallucinations
|
15-49%
|
|
Delusions
|
10-73%
|
|
Misidentifications
|
Up to 30%
|
|
Mania
|
3-15%
|
|
Personality change
|
Up to 90%
|
Anxiety
As a consequence of dementia, anxiety may be experienced by the resident in situations that did not cause anxiety prior to diagnosis, most commonly in unfamiliar environments or on being left alone [1, 4]. If left untreated, anxiety may escalate into catastrophic reaction, panic attack or phobia [1].
Depression
Depressed mood is one of the most commonly experienced BPSD, usually emerging in the early stages of dementia and more often in vascular dementia than others. Residents with dementia have a higher rate of depressive illness than those without cognitive impairment, and those with a past history of depression are more likely to experience depression as a consequence of dementia [1, 4, 7].
Depressive illness ranges from apathy (general loss of interest in life) to depressed mood and major depression. Whilst residents with apathy display similar symptoms as those with major depression (e.g. decrease in socialisation, initiative and emotional response) a diagnosis of depression associated with depression may be considered when the resident has a loss of pleasure in life, hopelessness, pervasive depressed mood, expression of the wish to die and/or worthlessness [1, 4]. Left untreated, depression not only decreases the quality of life for residents and their caregivers, but also leads to sleep disturbances and nutritional deficits [1].
Psychotic symptoms
Psychotic symptoms include delusions and hallucinations. Delusions (false beliefs) generally emerge in mid-stage dementia, with early presentation indicating a poor prognosis. The most common delusions experienced by adults with dementia are those of the paranoid type; for example believing that people are stealing things, that the spouse/caregiver is an imposter or of abandonment [1, 4]. Hallucinations may also be experienced, generally in the later stages of dementia. Visual hallucinations (for example seeing strangers in the absence of visual stimuli) are more common than auditory, however these must be differentiated from misidentification of the environment or sensory deficits [1, 4]. Psychotic symptoms, whilst decreasing the resident’s quality of life on their own, are also related to increase in aggressive behaviour [4].
Misidentification
In contrast to visual hallucinations, misidentification is related to misinterpretation of visual stimuli. The most commonly experienced misidentifications by adults with dementia are misidentifying other people, mistaking television for reality and misidentifying oneself [1, 4]. Misinterpretations may also be incorporated into the resident’s delusions and may contribute to aggression in some residents [4].
Behavioural symptoms
Behavioural symptoms commonly displayed by residents with dementia are outlined in Table Two.
Table Two: Incidence of behavioural symptoms in residents with dementia [2]
|
Behaviour
|
Incidence
|
|
Wandering
|
3- 53%
|
|
Inappropriate behaviour (e.g. hoarding)
|
10- 50%
|
|
Sexual disinhibition
|
10- 50%
|
|
Intrusive verbal and physical behaviours
|
41-49%
|
|
Restlessness
|
10- 50%
|
|
Physical aggression
|
10- 50%
|
Wandering
Wandering is not only one of the most common BPSDs, but also one which provides the most challenges to caregivers. It usually develops in early-mid dementia and gradually decreases. It is important to determine the type of wandering the resident experiences in order to develop the most appropriate management plan. Common types include [4]:
Checking behaviour – e.g. wandering to determine where the caregiver is; Trailing or stalking – following the caregiver with no intended purpose; Pottering; Absconding – wandering with the purpose of ‘escape’; Wandering with an inappropriate purpose – e.g. related to a delusion; Aimless wandering; and Night time wandering.
Wandering of itself may not be a problem to the resident however it may increase the resident’s risk of falls, impinge upon the rights of others and/or lead to nutritional deficits [4].
Agitation
Agitation refers to inappropriate verbal, vocal or motor activity not resulting from a specific need. Experience of agitation is related to type and stage of dementia, the resident’s general personality type and the environment [4]. Although agitation can be categorised in various ways, the Cohen-Mansfield Agitation Inventory (a frequently used assessment tool) identifies four major types [4, 8]:
Physically non-aggressive agitation; Verbally non-aggressive agitation; Physically aggressive agitation; and Verbally aggressive agitation.
Aggressive agitation is more often experienced in severe dementia when communication is more limited, in males and in those with poor social relationships and support. Verbally non-aggressive agitated behaviour is associated with depression and is seen more often in females. Physically non-aggressive agitation is more likely in residents with severe dementia [4, 8].
Intrusive behaviours
Intrusive behaviour incorporates both physical and verbal behaviour that intrudes upon other residents or the caregiver. Intrusive behaviours such as clinging, pushing, being verbally demanding without cause and taking others’ possessions occur in up to 50% of residents with mild-moderate dementia. These behaviours are a challenge to manage as often the resident is persistent, pushing others to eventually respond inappropriately [4].
Disinhibition
Disinhibition is a term to describe behaviour that is inappropriate and lacking in judgement and usually is a change from the resident’s pre-dementia personality. Behaviours such as crying, euphoria, verbal or physical aggression, self destructive behaviour, impulsiveness and sexual disinhibition not only causes concern for the caregiver but may bring harm to the resident or others [4].
Negativism
Negativism refers to behaviours of a negative nature that frequently impact upon staff, such as being uncooperative, stubborn, complaining for no appropriate reason and resistance to care. In some instances these behaviours may be associated with other symptoms such as delusions or agitation [4].
Catastrophic reactions
A catastrophic reaction is an excessive emotional or physical response to the environment. Occurring in mild-moderate dementia, catastrophic reactions are often associated with anxiety, delusions, hallucinations or misinterpretation of the environment or caregiver communication [4].
Assessment
Diagnosis
There is a risk that caregivers may incorrectly assume a resident is experiencing psychological or behavioural symptoms as a result of either dementia or normal ageing. Many of the BPSD are non-specific and may arise from a cause other than the resident’s dementia. Medical assessment of BPSD should first focus on identifying [1, 4, 6]:
Resident’s specific symptoms; Any underlying physical causes for the behavioural or psychological symptom; and Any medication side effects or drug-drug interactions (especially when there has been recent changes to medication regime) that may cause the behavioural or psychological symptom.
Clinical examination and investigations focus on ruling out other causes before determining the symptoms are a result of dementia [1, 4, 6]. Differential diagnoses are listed in Table Three. The importance of identifying delirium super-imposed upon dementia is discussed in the Clinical Information Sheet on Delirium.
Table Three: Differential diagnosis for BPSD [1, 4, 6]
|
Type of disorder
|
Diagnoses to consider
|
|
Metabolic
|
Hyper/Hypo thyroidism, hypercalcemia, hyponatremia, dehydration, delirium
|
|
Infections
|
Urinary tract infection, pneumonia, septicaemia
|
|
Traumatic
|
Chronic or acute pain, head trauma, fractures, fatigue, faecal impaction
|
|
Systemic
|
Hypoglycaemia, vitamin B12 deficiency, folate deficiency
|
|
Sensory
|
Vision or hearing impairment
|
|
Medications
|
Sedatives, antihistamines, alcohol, medication interactions
|
Assessment of symptoms
Before developing a management plan it is important to understand the specific symptoms the resident is experiencing, precipitating events, any patterns to the behaviour, and the consequences of the behaviour [1, 4, 6, 9].
Information can be collected from a variety of sources [4, 9]:
The resident: As dementia develops self-reporting becomes less reliable; Family /significant others: Familiar with the resident, however reporting may be influenced by education and mood; RACF staff: Have more experience in assessing residents and often spend more time observing and caring for the resident; and The medical team: Have the advantage of specialist skills, however, spend less time observing the resident.
Observing the resident and documenting the symptoms experienced regularly throughout the day over 1-2 weeks is required to establish patterns [8, 10]. Specific information to document during the assessment of residents displaying BPSD includes [1, 4, 6, 9]:
Precise behaviour exhibited by the resident – what happens and for how long; When does the behaviour occur – e.g. how often, time of day; How long does the behaviour last; Where does the behaviour occur – e.g. is it specific to one room, bright lights, noise; Precipitating events – what happened immediately before the behaviour occurred; Purpose of the behaviour – e.g. is the resident wandering to find a toilet or wandering with no aim; and Impact of the BPSD upon the resident and others in the RACF e.g. caregiver stress, increase in anxiety.
A general behaviour assessment tool for recording symptoms is provided in the Reference Card Behaviour Observation Chart. There are several validated tools for assessing various BPSD in older adults (see Table Four), some of which have been included in the reference cards. After assessing the resident’s behaviour over a period of time, try to establish patterns in when and why the BPSD occur.
Table Four: Assessment tools for various BPSD [2, 9, 11]
|
Symptom
|
Assessment tool
|
|
Depression
|
Cornell Scale
Dementia mood assessment scale (DMAS)
|
|
Agitation
|
Cohen-Mansfield Agitation Inventory (CMAI) (see Reference Card)
Brief Agitation Rating Scale (BARS)
Pittsburgh Agitation Scale
|
|
Negativism / mood
|
Irritability/apathy scale
Dementia mood assessment scale (DMAS)
|
|
Psychotic symptoms
|
Neuropsychiatric Inventory Questionnaire(NPI-Q) (see Reference Card)
Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD)
|
|
General behaviour
|
Behaviour Assessment Chart (see Reference Card)
Dementia Behaviour Disturbance Scale (DBD)
Neurobehavioural Rating Scale
Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD)
|
Sleep Assessment
Assess factors contributing to sleep disturbance: age-related changes to sleep cycles; age-related sleep disorders (e.g. sleep apnea); and illness such as COPD, chronic pain, cardiovascular disease and dementia [10, 12]. Not only do cognitive changes related to normal ageing and dementia impact upon sleep, but studies have also found that noise and light in the night-time environment contribute to sleep disturbance in residents of RACFs [12].
Wrist actigraphy (a monitoring device that measures sleep in relation to body movement) is the most accurate method for assessing sleep, however its use in dementia is limited by access, cost, and BPSD which cause the resident to interfere with the monitoring device [13]. Observing and documenting the resident’s night time behaviour may be effective in gathering an accurate assessment of sleep patterns when conducted on a frequent basis (more frequently than once/hour). Subjective reports of sleep quality provide insight into the residents’ experiences, even when the resident has dementia [12].
Management
Management is based on a detailed assessment of specific symptoms and contributing medical, psychological or environmental factors.
Treat underlying medical causes such as infection, delirium, pain [1, 7]. Cease medications that are unnecessary, change medications that may aggravate the specific symptoms. Address environmental factors such as under or over stimulation.
Management Plan
Consider whether specific symptoms need treatment, and who needs to be involved. Treatment of specific symptoms may include:
Non-pharmacological (behavioural and environmental) strategies; Medication to treat cognitive impairment, depression, anxiety, or psychotic symptoms if distressing or disruptive; Education of RACF staff and relatives/carers in behavioural and environmental strategies; Specialist consultation for education, advice and/or management of severe problems; and Placement in a specialist facility for severe BPSD is occasionally needed for safety of the resident or others.
Some general strategies to use in management plan development are to [10]:
Address one symptom at a time; Set realistic goals and allow time for the plan to be effective; Generate a variety of management strategies and try one at a time; Decide how to assess the effectiveness of strategies (e.g. a reduction in length of time resident experiences the symptom; reduction in number of events); and Regularly evaluate and modify the management plan with input from the resident and his or her family, RACF staff and general practitioner.
Non-pharmacological Strategies
Behavioural, environmental and other non-pharmacological interventions are recommended as first line treatment for BPSD. To be effective these interventions need to be designed to meet the resident’s individual needs and then continuously assessed and refined until the resident’s BPSD is well managed. Studies have found that psychotropic medications are over-prescribed in RACFs and in many instances these medications are ineffective in long-term management of BPSD therefore their use should be considered cautiously [1, 6, 9, 10, 14]. The use of physical restraints poses significant risks to the resident and may also increase symptoms such as agitation. Their use is not recommended in RACFs [8].
Behavioural strategies
Behaviour management can be based on the principles of A-B-C-D outlined in Figure One [6, 10]:
A = an activating event influences the resident’s behaviour; B = behaviour occurs as a result of A; C = consequences occur due to the behaviour; and D = de-escalation of the behaviour, deciding on strategies and debriefing after the event.
Select behavioural strategies with consideration to the events that precipitate the resident’s symptoms, and the resident’s personal preferences, habits and pre-dementia personality. Below are strategies that have been implemented effectively to manage BPSD[1, 8, 10]:
Develop and maintain a simple daily routine. Be prepared for change and inconsistencies in the resident’s wants and abilities. Consider the resident’s personal preference in routine, activities of daily living and food choices. Ensure the resident uses his or her sensory aids, and is regularly assessed for sensory deficits. Ignore inappropriate behaviour or walk away from the resident. Positively reinforce appropriate behaviour. Use distraction to divert the resident from precipitating events. When interacting with the resident avoid rushing; give the resident time to adapt and respond. If the resident resists a particular task, try again at another time. Be tolerant of behaviour if it is not posing any risks. Be flexible in the timing of meals and sleep.
Figure One: A-B-C Behaviour Management adapted from Snell et al [6]
Communication skills are an important component of behaviour management. Below are strategies to help the resident understand your meaning and to avoid triggering or escalating BPSD [1, 8, 10]:
Promote the resident’s dignity and individuality. Use empathy and humour. Avoid arguing with the resident or reprimanding inappropriate behaviour. Provide regular orientation cues and reminders. Explain what you are going to do before you start care tasks. Use words and statements appropriate to the resident’s educational level. Use clear, short and simple sentences. Break instructions down into step-by-step tasks. Use appropriate eye contact, body language and touch to support your message. Avoid using phrases that may trigger BPSDs e.g. at staff change-over, avoid phrases like “Bye, I’m going home now” or “I’ve got to go and pick the kids up”. For residents at risk of absconding, ensure that staff are aware of whom is responsible for supervision, keep an up-to-date description and photograph of the resident and consider registering the resident as a wanderer with the local police.
Environmental strategies
To reduce BPSD the environment should be adapted to the resident’s needs rather than forcing the resident to adapt to the environment. Creating a familiar and calming environment that promotes orientation and decreases confusing stimulation has been shown to be effective in reducing BPSD. Consideration should also be given to the safety of residents who wander. Suggested strategies are below [1, 8, 10]:
Maintain an appropriate temperature. Use calm colours for decore and staff attire. Consider the lighting. Low lighting can be calming, but may also be dangerous for mobile residents or decrease the resident’s ability to see and interpret the environment. Create a home-like environment and avoid rearranging furniture or rooms too often. Use visual barriers (e.g. camouflage) to deter residents who attempt to leave the facility. Reduce extraneous noise, use curtains/carpets to reduce noise. Display clocks and calendars. Remove loose rugs, electrical cords etc to prevent falls. Provide access to safe walking areas (use sun protection outdoors). Consider using electronic alarms or digital locks to prevent residents absconding. Provide stimulating activities and social opportunities with consideration to the resident’s preferences.
Nutrition
BPSD may impact upon the resident’s nutrition, with up to 92% of adults with dementia losing weight [10]. In early dementia those who are aware of their deficits may avoid social situations, impacting upon mealtimes. In mid-late dementia, memory loss, apathy, depression, inappropriate behaviour and wandering may contribute to weight loss [1, 10]. . Nutritional strategies include [1, 8, 10]:
Consider personal taste in food choices. Ensure food is appetising and prepared in a way that the resident can eat it (e.g. cut up, blended). Identify residents at risk of weight loss and provide assistance and supervision. Provide regular nutritious snacks that can be eaten ‘on-the-run’ for wandering residents. Be flexible in mealtimes.
Aromatherapy and Massage
Aromatherapy and hand massage have been used effectively to reduce agitation and psychotic symptoms in some populations with severe dementia [3, 10, 15, 16], although others have found no effect or worsening of symptoms [10, 16]. It is likely that response to these interventions is highly personal depending upon the resident’s past history, preferences and allergies. Either Melissa or Lavender essential oils have been used with a positive outcome using oil burners or blended with a massage lotion for application to hands and face [15]. Other essential oils used to reduce agitation include Peppermint, Sweet Marjoram, and Rose [16].
Recreational strategies
Music
Music therapy may be effective for managing BPSD in some residents, particularly those for whom music has played a role in their earlier lives [1, 10, 11, 17]. Background music is effective in reducing psychotic symptoms, anxiety and agitation in various populations, suggesting it may also be beneficial in the management of BPSD, although there has currently been insufficient research in those with dementia to make conclusive recommendations [18]. Evidence suggests that gentle music from the resident’s teen years, own country and own culture is likely to be most effective in reducing BPSD [10].
Individual music programs may also be developed with the resident’s specific musical interests in mind to manage agitation, aggressiveness and some mood symptoms. Before commencing therapy, interview the resident and/or significant others to determine particular likes and dislikes (e.g. identify a specific genre of music or album enjoyed by the resident). A recording can be developed to the resident’s preferences with the assistance of family members or public library resources. Individual music programs have been found to have the most positive effect if played to the resident for a minimum of 30 minutes prior to timing of the resident’s peak BPSD [11]. Monitor the resident’s behaviour and mood to assess the effectiveness of the intervention [1, 10, 11, 17].
Pets
Pet therapy – allowing supervised interaction with domestic pets – has been used effectively to improve mood, social interaction and as a distraction to BPSD. Incorporating pet therapy into the RACF’s activity program may be beneficial to some residents with BPSD [1, 3, 17].
Relaxation
Relaxation therapy may be incorporated into the resident’s lifestyle program by RACF with training in this field. For some residents, especially those in early stages of dementia, relaxation skills may reduce anxiety, agitation and aggressiveness [3].
Psychological strategies
Specific psychological interventions, such as reality orientation, validation therapy and reminiscence, have been used for the management of BPSD. Their effectiveness is dependent upon the resident’s level of dementia, personal preferences and past history; the experience and persistence of staff and the general philosophy of care used by the RACF.
Reality orientation
Reality orientation involves the continuous reorientation of the resident by presenting current information (e.g. the date, time, location) during interactions. The aim of this intervention is for staff members to provide a commentary on current events to reduce the resident’s disorientation and associated agitation/anxiety [19].
Validation therapy
Validation therapy is based on the general principle that residents with dementia have an altered perception of reality and short term memory deficits that make understanding current reality a challenge. Therapy focuses on reinforcing the resident’s own view of reality [19, 20] To incorporate this intervention into the resident’s care RACF staff require specific training in the philosophy and techniques. Although some researchers have had success managing BPSDs including agitation and anxiety, findings on effectiveness are mixed [20].
Reminiscence
Reminiscence therapy is an intervention in which the resident is encouraged to recall past life events, either on a one-to-one basis with the therapist or within a group. Audiovisual aids such as photographs, sound recordings, familiar items, newspaper articles etc may be used to prompt memory and discussion [1, 19, 21]. Although research findings on the effectiveness of reminiscence therapy in managing BPSD are inconclusive [21], reminiscence is one of the most popular psychological interventions used in RACF [19]. It is thought that stimulating the resident’s long-term memory may be beneficial, and recognition of the resident’s past allows for the important old-age process of life review [19].
Sleep strategies
A number of interventions for the promotion of regular sleep patterns have been trialed in general populations of older adults as well as those with dementia.
Sleep hygiene
General strategies recommended to promote sleep include [10]:
Maintain a regular bedtime and rising time; Use the bed primarily for sleeping in; Maintain a bedtime ritual; Reduce intake of alcohol, caffeine and nicotine; Decrease evening fluid intake, unless contraindicated; and Review medication regime – consider medications that may interfere with sleep and substitute or alter dosage time.
Environmental sleep strategies
Night-time nursing care, particularly in nursing homes, involves increase in noise and light levels that results in major disruption to sleep. Noise abatement protocols have a role in promoting an environment more conducive to sleep, and should be used in association with other management strategies. Examples of strategies include [10, 12]:
Closing consenting residents’ doors at night; Reducing noise from televisions by decreasing volumes after an agreed upon time; Switching off unwatched televisions; Reducing hall lights and turning off unnecessary lighting; Encouraging the use of headphones when watching television (be aware this may cause increased confusion in those with dementia); and Requesting staff to lower their voices.
Incontinence and pressure area care has also been found to be disruptive to sleep in residents of RACFs. Care routines that minimise disturbance to residents’ sleep for incontinence and pressure area care have a positive effect on sleep while not impacting negatively on skin condition in the short term, although research has not investigated the long term effects. Regular skin breakdown risk assessments should be conducted to develop appropriate individualised night-time care regimes that consider the resident’s need for uninterrupted sleep [12].
Daytime activity
Physical exercise and increased daytime activity have been suggested as strategies to improve night-time sleep in older adults. Research is inconclusive on the effect on sleep of increased physical activity. Individualised activity interventions and daytime programs to meet residents’ specific interests and physical capabilities including board games, ball games, music and simple crafts are effective in promoting night-time sleep [12].
Aromatherapy
Current research on use of aromatherapy to promote sleep in older nursing home populations suggests its use
may be of therapeutic benefit. Either lavender (Lavendula officiales), roman chamomile (Anthemis nobilis) and a blend of these two essential oils may be administered via an aromatherapy oil burner or as a few drops on the resident’s pillowcase [12].
Bright light therapy
Recent research suggests that bright light therapy is difficult to administer, beneficial effects on night-time sleep are minimal and there is a risk of exacerbating disruptive behaviours in residents with dementia [12].
Medication
Psychotropic medications are regularly used inappropriately in RACFs and in many instances these medications are ineffective in long-term management of BPSD. When medication is used in the management of BPSD it should be used in conjunction with non-pharmacological strategies [1, 3, 6, 9, 10, 14].
Psychotropic medication should be given for specific indications, based on assessment of symptoms. Useful medications include antidepressants, short acting anxiolytics, atypical antipsychotics, and anticholinesterase inhibitors. Anticonvulsants can sometimes be helpful for managing agitation and aggression.
The general principles to observe when prescribing medication to manage behavioural and/or psychological symptoms in older adults are [1, 3, 6, 9, 10, 14]:
Document the target symptom and the goals of medication treatment; Start with a low dose; Gradually increase the medication until symptoms are controlled; Consider the resident’s behaviour patterns when determining administration times; Monitor for both positive response and for side-effects, which are more common in older adults; If the resident displays adverse effects change to a different medication rather than adding additional drugs; and Medication should be time-limited (maximum 12 weeks) – once the BPSD is controlled attempt withdrawing medication and if signs and symptoms resume, recommence.
For residents who experience episodes of extreme aggression, agitation or psychosis the administration of an intramuscular antipsychotic or benzodiazepine may be effective for short-term symptom control [3]. The safety of staff, the resident and others should be considered before prescribing intramuscular medication.
Antidepressants
Antidepressant medication may be effective in managing mood disturbances experienced by adults with BPSD in early stages of dementia [1, 3, 14]. When depression is considered to be a problem, a trial of antidepressant medication for an initial period of 6-12 weeks is recommended [3].
Selective serotonin re-uptake inhibitors (SSRIs) have been shown to be effective in managing depression in older adults and the low rate of non-serious side effects (e.g. nausea, restlessness, dizziness, increase in falls risk, weight loss, and insomnia) makes them the antidepressant of choice [1, 3, 14]. As hyponatremia may occur in some elderly individuals (syndrome of inappropriate antidiuretic hormone), it is advisable to check serum sodium level at commencement and again within a month [7]. Recent studies have shown an increased risk of gastrointestinal bleeding, particularly in susceptible people taking aspirin and/or a NSAID [7]. See the box below for SSRIs and recommended doses.
|
SSRI Antidepressants [7]
|
|
Medication
|
Therapeutic Range
|
|
Citalopram
|
20mg orally daily in the morning (usual effective dose), may increase at 2-4 week intervals to maximum of 60mg daily
|
|
Fluoxetine
|
20mg orally daily in the morning (usual effective dose), may increase at 2-4 week intervals to maximum of 40-80mg daily
|
|
Fluvoxamine
|
50mg orally daily in the evening, may increase after 1 week to 100mg (usual effective dose); may increase at 2-4 week intervals to maximum of 300mg daily
|
|
Paroxetine
|
20mg orally daily in the morning (usual effective dose), may increase at 2-4 week intervals by 10mg to maximum of 50mg daily
|
|
Sertraline
|
50mg orally daily in the morning (usual effective dose), may increase at 2-4 week intervals to maximum of 200mg daily
|
There is no solid evidence supporting the use of tricyclic antidepressants in the management of BPSD. Due to frequently observed side effects in older adults use of these medications should be considered with caution [14]. Antidepressants with anticholinergic adverse effects may exaggerate cognitive impairment and should be avoided [7].
Anxyolitics
Anxyolitics are primarily used for anxiety, irritability, agitation and sleep disturbances [14]. Side effects include increase in confusion and memory disturbances, ataxia, sedation and a significant increase in the risk of falls. Short-acting benzodiazepines such as oxazepam (15 mg orally 1 to 4 times a day) should be selected for use in older adults rather than longer-acting preparations, due to a lower rate of side effects [1, 14]. It is recommended that anxyolitics be used for time-limited periods of 2-6 weeks with a gradual tapering of dose whilst observing for recurrence of symptoms [7], [14].
Despite the wide-spread use of medications to manage sleep disturbances in RACF residents, research suggests benzodiazepines, neuroleptics and antidepressants do not have a substantial effect in the long term management of improving the sleep of residents in RACFs (or those with dementia) [12]. A beneficial effect may be observed in some residents if medication is used for short term (2-4 week) courses in conjunction with other management strategies [12]. Short-acting benzodiazepines (e.g. temazepam 5-20mg at bedtime) are the most appropriate for use in older adults [1, 10].
Antipsychotics
Antipsychotics may be considered to help in the management of psychotic symptoms, agitation or physical aggression, although RCTs suggest that conventional antipsychotics produce modest positive outcomes in only 18-26% of residents [1, 14]. Research has found that psychotropic medication is ineffective in treating wandering or disinhibition without significant adverse effects [1].
Atypical antipsychotics such as risperidone and olanzapine are recommended for use in older adults in preference to traditional antipsychotics (e.g. haloperidol) due to the lower incidence of extrapyramidal side effects [1, 3, 7, 17]. Riseridone should be used with caution in people with known cardiovascular disease, as it has been associated with an increased incidence of cerebrovascular events [7, 14]. To control hallucinations, delusions or seriously disturbed behaviour recommended doses are risperidone 0.5-1.0mg orally, daily in 1 or 2 doses; or olanzapine 2.5-10mg orally, daily in 1 or 2 doses. [7, 14]
Side effects of typical antipsychotic medications include sedation; increase in confusion and cognitive deterioration; increased risk of death; possible increased risk of CVA; and a high risk of tardive dyskinesia [1, 3, 14, 22]. Higher potency medications (e.g. haloperidol, thiorhixene) may also produce extrapyramidal side effects including drooling, rigidity and akinesia, whilst residents taking lower potency preparations (e.g. thioridazine, chlorpromazine) may experience anticholinergic side effects including postural hypotension, dry mouth, constipation and blurred vision [14].
Typical antipsychotics should never be used in residents with Lewy bodies dementia or Parkinson’s disease [7].
Anticonvulsants
Anticonvulsants, Carbamezapine (300-800mg/day) and Valproic acid (400-1,000mg/day), have been shown to be effective in managing psychotic symptoms, agitation and aggression secondary to brain damage in older adults with dementia [3, 14].
Cholinesterase inhibitors
Cholinesterase inhibitors have shown a small positive benefit when used to delay and manage BPSDs including apathy, hallucinations, depression and anxiety [14, 17]. A variety of cholinesterase inhibitors have been trialed with mixed results dependent upon the type of dementia experienced by the resident. Side effects of cholinesterase inhibitors include anorexia, nausea, vomiting, diarrhoea, insomnia, asthma, bradyarrhythmias, cramps and dizziness [3, 7]. Monitor residents with asthma, chronic obstructive pulmonary disease, cardiac disease, and peptic ulcer disease closely. Galantamine is contraindicated in severe renal failure [7].
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Cholinesterase inhibitors [3, 7, 14]
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Type of Dementia
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Medication
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Therapeutic Range
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Recommended Time Period
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Alzheimer’s
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Donepezil
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10 mg/day
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12 to 52 weeks
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Vascular
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Galantamine
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24 mg/day
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24 weeks
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Lewy bodies
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Rivastigmine
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12 mg/day
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20 weeks
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Sources of Information
Where to go for more information
Alzheimer’s Australia
Alzheimer’s Australia provides a variety of education and support programs for people with dementia and their carers. The group provides a national telephone service for support and advice provided by professionals and provide free education material such as the Dementia Education and Support Program available from the website.
National Dementia Helpline: 1800 639 331.
Website: http://www.alzheimers.org.au
National Dementia Behaviour Advisory Service
This is a Commonwealth funded service that provides advice on managing behavioural and psychological symptoms of dementia. This telephone based service provides assistance on the assessment and management of BPSD as well as providing general dementia education and caregiver support.
Phone: 1300 336 448 (24 hours, 7 days)
References
Bridges-Webb, C. , Wolk, J., al, et, Care of Patients with Dementia in General Practice Guidelines. 2003, Royal Australian College of General Practitioners, (RACGP)
NSW Health, (NSWH): Sydney, Australia. International Psychogeriatric Association, (IPA), Module One, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. National Collaborating Centre for Mental Health, (NCCMH), Dementia - Supporting People with Dementia and their Carers (Draft for Consultation). 2006, Social Care Institute for Excellence, (SCIE)
National Institute for Health and Clinical Excellence, (NICE): UK. International Psychogeriatric Association, (IPA), Module Two, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. International Psychogeriatric Association, (IPA), Module Three, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. Snell, T., Crombie, A., Boyd, J., Making Behaviour Management as easy as ABC! 2006, Bendigo Health: Bendigo, Victoria, Australia. eTG, Dementia - Psychotropic; Neurology, in http://www.tg.com.au (accessed August 2006), eTG. 2005 Cohen-Mansfield, J., Managing Agitation in Elderly Patients With Dementia. Geriatric Times, 2001. 2(3). Forester, B.,Oxman, T., Measures to Assess the Noncognitive Symptoms of Dementia in the Primary Care Setting. Journal of CLinical Psychiatry, 2003. 5(4). International Psychogeriatric Association, (IPA), Module Five, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. Gerdner, L., Evidence-based protocol. Individualized music. 2001, University of Iowa Gerontological Nursing Interventions Research Center Research Dissemination Core: Iowa City. p. 35. Haesler, E., Systematic Review: Effectiveness of strategies to manage sleep in residents of aged care facilities. JBI Reports, 2004. 2: p. 115–183. Gasio, P., Krauchi, K. , Cajochen, C., al., et, Dawn–dusk simulation light therapy of disturbed circadian rest-activity cycles in demented elderly. Exp Gerontol, 2003. 38: p. 207–16. International Psychogeriatric Association, (IPA), Module SIx, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. Ballard, C., O’Brien, J., Reichelt , K., Perry, E., Aromatherapy as a Safe and Effective Treatment for the Management of Agitation in Severe Dementia: The Results of a Double Blind, Placebo Controlled Trial. 1999, Wolfson Research Centre Newcastle General Hospital: Newcastle upon Tyne, UK. p. 18. Thorgrimsen, L., Spector, A., Wiles, A., Orrell, M., Aroma therapy for dementia. Cochrane Database of Systematic Reviews, 2003(3). American Geriatric Society Clinical Practice Committee, (AGSCPC), Guidelines Abstracted from the American Academy of Neurology's Dementia Guidelines for Early Detection, Diagnosis and Management of Dementia. 2002, Amerian Geriatric Society: New York, NY. Vink, A., Birks, J., Bruinsma, M., Scholten, R., Music therapy for people with dementia. Cochrane Database of Systematic Reviews, 2003(4). Morton, I.,Bleathman, C., The Effectiveness Of Validation Therapy In Dementia-A Pilot Study. International Journal Of Geriatric Psychiatry, 1991. 6: p. 327-330. Neal, M.,Wright, P., Validation therapy for dementia. Cochrane Database of Systematic Reviews, 2002(3). Woods, B., Spector, A., Jones, C., Orrell, M., Davies, S., Reminiscence therapy for dementia. Cochrane Database of Systematic Reviews, 2005(2). eTG, Dementia Update (Neurology Therapeutic Guidelines), in http://www.tg.com.au (accessed August 2006), eTG. 2005 National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
Background information on the management of Behavioural and Psychological Symptoms of Dementia (BPSD) provided in this Clinical Information Sheet (CIS) is based on evidence produced by expert opinions in the field, particularly guidelines produced by the International Psychogeriatric Association in 2006. Supporting evidence is based on additional Level I evidence sources from The Cochrane Collaboration.
The following table outlines the level of evidence of each reference:
|
|
Reference |
Year |
Level of Evidence |
1. |
Bridges-Webb, C. , Wolk, J., al, et, Care of Patients with Dementia in General Practice Guidelines. 2003, Royal Australian College of General Practitioners, (RACGP)NSW Health, (NSWH): Sydney, Australia. |
2003 |
Level IV B evidence |
2. |
International Psychogeriatric Association, (IPA), Module One, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. |
2002 |
Level IV B evidence |
3. |
National Collaborating Centre for Mental Health, (NCCMH), Dementia - Supporting People with Dementia and their Carers (Draft for Consultation). 2006, Social Care Institute for Excellence, (SCIE)National Institute for Health and Clinical Excellence, (NICE): UK. |
2006 |
Level I evidence |
4. |
International Psychogeriatric Association, (IPA), Module Two, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. |
2002 |
Level IV B evidence |
5. |
International Psychogeriatric Association, (IPA), Module Three, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. |
2002 |
Level IV B evidence |
6. |
Snell, T., Crombie, A., Boyd, J., Making Behaviour Management as easy as ABC! 2006, Bendigo Health: Bendigo, Victoria, Australia. |
2006 |
Level IV C evidence |
7. |
eTG, Dementia - Psychotropic; Neurology, in http://www.tg.com.au (accessed August 2006), eTG. 2005 |
2006 |
Level IV C evidence |
8. |
Cohen-Mansfield, J., Managing Agitation in Elderly Patients With Dementia. Geriatric Times, 2001. 2(3). |
2001 |
Level IV C evidence |
9. |
Forester, B.,Oxman, T., Measures to Assess the Noncognitive Symptoms of Dementia in the Primary Care Setting. Journal of Clinical Psychiatry, 2003. 5(4). |
2003 |
Level I evidence |
10. |
International Psychogeriatric Association, (IPA), Module Five, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. |
2002 |
Level IV B evidence |
11. |
Gerdner, L., Evidence-based protocol. Individualized music. 2001, University of Iowa Gerontological Nursing Interventions Research Center Research Dissemination Core: Iowa City. p. 35. |
2001 |
Level I evidence |
12. |
Haesler, E., Systematic Review: Effectiveness of strategies to manage sleep in residents of aged care facilities. JBI Reports, 2004. 2: p. 115–183. |
2004 |
Level IV A evidence |
13. |
Gasio, P., Krauchi, K. , Cajochen, C., al., et, Dawn–dusk simulation light therapy of disturbed circadian rest-activity cycles in demented elderly. Exp Gerontol, 2003. 38: p. 207–16. |
2003 |
Level III evidence |
14. |
International Psychogeriatric Association, (IPA), Module SIx, in Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack, International Psychogeriatric Association, (IPA), Editor. 2002, International Psychogeriatric Association, (IPA): Skokie, IL, USA. |
2002 |
Level IV B evidence |
15. |
Ballard, C., O’Brien, J., Reichelt , K., Perry, E., Aromatherapy as a Safe and Effective Treatment for the Management of Agitation in Severe Dementia: The Results of a Double Blind, Placebo Controlled Trial. 1999, Wolfson Research Centre Newcastle General Hospital: Newcastle upon Tyne, UK. p. 18. |
1999 |
Level II evidence |
16. |
Thorgrimsen, L., Spector, A., Wiles, A., Orrell, M., Aroma therapy for dementia. Cochrane Database of Systematic Reviews, 2003(3). |
2003 |
Level I evidence |
17. |
American Geriatric Society Clinical Practice Committee, (AGSCPC), Guidelines Abstracted from the American Academy of Neurology's Dementia Guidelines for Early Detection, Diagnosis and Management of Dementia. 2002, Amerian Geriatric Society: New York, NY. |
2002 |
Level IV B evidence |
18. |
Vink, A., Birks, J., Bruinsma, M., Scholten, R., Music therapy for people with dementia. Cochrane Database of Systematic Reviews, 2003(4). |
2003 |
Level I evidence |
19. |
Morton, I.,Bleathman, C., The Effectiveness Of Validation Therapy In Dementia-A Pilot Study. International Journal Of Geriatric Psychiatry, 1991. 6: p. 327-330. |
1991 |
Level IV A evidence |
20. |
Neal, M.,Wright, P., Validation therapy for dementia. Cochrane Database of Systematic Reviews, 2002(3). |
2002 |
Level I evidence |
21. |
Woods, B., Spector, A., Jones, C., Orrell, M., Davies, S., Reminiscence therapy for dementia. Cochrane Database of Systematic Reviews, 2005(2). |
2005 |
Level I evidence |
22. |
eTG, Dementia Update (Neurology Therapeutic Guidelines), in http://www.tg.com.au (accessed August 2006), eTG. 2005 |
2006 |
Level IV C evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using an adapted version of the NHMRC (1995) [23] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material, eg developed in RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Dementia: Behavioural and Psychological Symptoms
The following reference cards are designed to be used in conjunction with the Dementia: Behavioural and Psychological Symptoms Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
The Neuropsychiatric Inventory Questionnaire
Cohen Mansfield Agitation Inventory
Behaviour Observation Chart
Sleep Assessment
Downloads and Printing
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To download the Clinical Information Sheet and/or the entire Reference Card package for this CIS, use the buttons below. To download, click on the link and select save to disk. You will be asked to select a folder in which to save the document. To download individual Reference Cards use the links above. Downloads are in printable formats.
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