Behavioral and psychological symptoms of dementia


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Behavioral and psychological symptoms of dementia

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Behavioral and psychological symptoms of dementia

  1. 1. Behavioral and psychological symptoms of dementia(BPSD) and their management: Dr.Roopchand.PS Senior Resident Academic Department of Neurology
  2. 2. Introduction: • Behavioral changes, paranoid delusions, hallucinations and long periods of screaming were described by Alzheimer in 1907 in his original case description of the disease. • An integral part of dementia syndrome. • BPSD is associated with a more rapid rate of cognitive decline and greater impairment in activities of daily living.
  3. 3. • A burden to patients and care givers. • Costs significantly to overall cost of dementia care. • Most of them are treatable.
  4. 4. Prevalence: • Reported prevalence of BPSD ranges from 50%100%. • BPSD were severe in 36.6% of the patients, moderate in 49.3%, and mild in 14.1%. • Depression, apathy and anxiety were the most common. • Depending upon cognitive levels, variation in BPSD frequencies have been reported. – 92.5% in patients with a MMSE between 11 and 20. – 84% of the patients with a MMSE between 21 and 30.
  5. 5. FEATURES OF BPSD: • Myriad manifestations. • Inappropriate behaviors: – Physically aggressive behavior : hitting, kicking or biting – Physically nonaggressive behavior: pacing or inappropriately handling objects – Verbally non aggressive agitation: constant repetition of sentences or requests. – Verbal aggression: cursing or screaming
  6. 6. • 24% and 48% of dementia patients have motor behavioural abnormalities. • Physical violence and hitting occurs in approximately 30% in Alzheimer’s dementia (AD). • Predictors of aggressive behavior: – Premorbid history of aggression – Troubled premorbid relationship between caregiver and patient – Multiple problems.
  7. 7. • Wandering: – Quarter fo AD patients have wandering. – Elderly wanderers have language impairment, disorientation and hyperactivity compared to non wanderers. – Wanders exhibit better social skills and are less withdrawn. • Mood Disturbances: – Depression is common. – may not have a typical presentation. – lack of sad or depressed affect.
  8. 8. • Depressive cognitions, death wishes are common. • Anxiety, fear, irritability, anger are also seen. • Apathy : 70-90% of AD. • Syndrome of decreased initiation and motivation, decreased social engagement, emotional indifference, diminished reactivity and lack of persistence.
  9. 9. • Apathy or Depression? – Dysphoria, hopelessness, guilt, self-criticism, suicidal ideation, sleep problems and appetite disturbances are associated with depression. • Personality change: – Increasing passivity, coarsening of affect, decreased spontaneity, inactivity, feelings of insecurity, less cheerfulness and responsiveness. – Reduced initiative and drive, grossly insensitive behavior, lack of restraint, disinhibition, sexual misadventure, indolence, foolish jokes and pranks
  10. 10. • Psychotic features: – usually paranoid in nature. – some one is stealing things, being present in the room, living inappropriately in the home (phantom boarder), mishandling personal finances, planning to harm physically. – delusions of infidelity, hypochondriasis, zoopathy, dead relatives being still alive, erotomania, Capgras syndrome, believing television images are real, personal images in a mirror is a different person, misidentifying own home.
  11. 11. • Other symptoms: – Screaming is seen in 25%. – high degree of dependency for ADL. – Sleep disturbance. – Dependency for excretory functions and hygiene maintenance come as a burden to caregivers.
  12. 12. TYPES OF DEMENTIA AND BPSD: • Some type of BPSD are more common in certain type dementia. • AD: – Aspontaneity and reduced initiative in early stages. – Behavioral symptoms occur ad disease progress. – Aggression, wandering, incontinence, and at least one symptom of Klüver-Bucy syndrome was found in 72%.
  13. 13. • DLB: – Visual hallucinations- more complex, vivid and rapidly moving. – Auditory hallucinations, persecutory delusions. – Fluctuating. • VaD: – Judgment and insight is relatively preserved. – Extreme anxiety and depression. – Lability and explosive emotional outbursts, episodes of noisy weeping or laughing
  14. 14. • Pick’s dementia: – Changes of character and social behavior more. – Fatuous euphoria or apathy,insensitive behavior, lack of restraint, and sexual misadventure have been seen. – Hypermetamorphosis occur early than AD. • Dementia due to Huntington’s disease: – Emotional disturbance is a prominent premonitory feature. – BPSD are reported for some considerable time before chorea. – Paranoid developments may be earliest manifestation. – Delusions of persecution, religiosity, reference and grandiosity are common. – schizophrenic or paraphrenic illness may be present for years before HD.
  15. 15. • Creutzfeldt-Jakob disease (CJD): – characterized by neurasthenic symptoms. – Fatigue, insomnia, anxiety, depression, mental – slowness and unpredictability of behavior, auditory hallucinations and delusions are the usual complaints. • Alcoholic dementia: – Profound social disorganization – Deterioration of personality.
  16. 16. ETIOLOGY OF BPSD: • Various theoretical models have been proposed. • ‘Unmet needs’ model • A behavioral/learning model • Environmental vulnerability/reduced stressthreshold model. • Premorbid personality has also been linked to BPSD.
  17. 17. • It has been suggested that some BPSD could be the consequence of both dementia and an undiagnosed comorbid bipolar spectrum disorder or a pre-existing bipolar diathesis pathoplastically altering the clinical expression of dementia.
  18. 18. • An imbalance of different neurotransmitters (acetylcholine, dopamine, noradrenaline, sero tonin,GABA) has been proposed as the neurochemical correlate of BPSD. – increased norepinephrine (NE) activity and/or hypersensitive adrenoreceptors compensating for loss of NE neurons – in AD – Increased activity of dopaminergic neurotransmission and altered serotonergic modulation of dopaminergic neurotransmission is associated with agitated and aggressive behavior in FTD.
  19. 19. • DAT1 3’-UTR VNTR polymorphism may play a role in BPSD susceptibility.
  20. 20. ASSESSMENT: • Depends on history from care giver. • Specific assessment scales are available. – Apathy Evaluation Scale (AES) – Behavioural Rating Scale for Geriatric Patients – Behaviour Pathology in Alzheimer’s Disease Rating Scale (BEHAVEAD) – Behavioural Rating Scales for Dementia – Cohen-Mansfield Agitation Inventory (CMAI) – Cornell Scale for Depression in Dementia (CSDD) – Frontal Systems Behaviour Inventory (FrSBe) – Neuropsychiatric Inventory (NPI) – Neuropsychiatric Inventory– Nursing Home version (NPI-NH) – Apathy Inventory (AI) – Behavioural and Psychological Symptoms Questionnaire (BPSQ).
  21. 21. MANAGEMENT OF BPSD: • Psychological, behavioral, environmental, and pharmacological interventions. • Nonpharmacological intervention is the preferred initial method of intervention for BPSD.
  22. 22. Nonpharmacological Intervention
  23. 23. Environmental modifications: • Environment around the patient can be modified for a beneficial effect on the BPSD. • Simulated home environment with appropriate visual, auditory and olfactory stimuli which may decrease the chance of trespassing, exit seeking and other agitation behaviors. • Reduced stimulation environments. • Environment can be modified by installing adequate daytime lighting to improve sleep patterns in patients with disturbed sleep wake cycles.
  24. 24. Social interactions: • One to one interaction for 30 min per day for 10 days has been found to be effective in decreasing verbally disruptive behavior. • Regular intensive interaction help in reality orientation. • Socialization can be increased by group activity, conjoint tasks and simple games. • Displaying photos of near relatives. • Pet therapy.
  25. 25. Minimize the impact of sensory deficits: • Corrective eyeglasses and hearing aids decrease risk of disorientation. • Slow and repetitive explanations reduce confusion and agitation.
  26. 26. Medical and nursing interventions: • Prompt management of pain is helpful. • Adequate sleep hygiene – decreases agitation. • Agitation secondary to fatigue and circadian rhythm disturbances can be reduced by bright light therapy. • Music therapy has been shown to be effective to reduce BPSD in patients with moderatesevere dementia.
  27. 27. Behavioral interventions: • Extinction, differential reinforcement and stimulus control. • Reinforcements include social reinforcements, food, touch, going outside, etc. • Consistent daily routines. • Exercises, removal of restraints, and adequate rest help in reducing the inappropriate behavior. • Spiritual and religious activities.
  28. 28. Pharmacological Intervention:
  29. 29. References: • Nilamadhab Kar; Behavioral and psychological symptoms of dementia and their management; Indian J Psychiatry. 2009 January; 51(Suppl1): S77–S86. • Manjari Tripathi, Deepti Vibha; An approach to and the rationale for the pharmacological management of behavioral and psychological symptoms of dementia; IAN 2010; 9 • Franz Müller-Spahn,MD; Behavioral disturbances in dementia. • Bradley's Neurology in Clinical Practice, 6th edition