Management of Behavioural and Psychological Symptoms of Dementia
by Stephen Abela
MD MRCP(UK) M PHIL MHSc HSM
Department for the Elderly and Community Care
Last year we have published an article which focused on the initial assessment of people presenting with symptoms suggestive of dementia (available on: www.thesynapse.net.mt).
The following article will now focus on important developments in the management of behavioural and psychological symptoms in dementia. This second article is directed in particular to primary care professionals and serve to highlight some important principles and newer approaches that are being recommended. This is a very important subject especially since there are many misconceptions on how to deal with these complaints.
Recently, there have been many publications expressing concern towards the inappropriate and excessive use of neuroleptic medication in dementia. In 2004, a safety message was issued by the Committee on Safety of Medicines of the United Kingdom concerning the use of atypical antipsychotics in patients with behavioural and psychiatric symptoms of dementia. This alert followed the analysis of manufacturer data which showed an increased risk of cerebrovascular adverse events with risperidone and olanzapine. The magnitude of increased risk in the studies analysed was in the region of three times. It has been recommended that these drugs are prescribed only following a careful assessment of benefits and risks, are used in the lowest possible dose and for a specified period of time. Although the other ‘typical’ neuroleptic drugs are commonly prescribed to treat behavioural and psychiatric symptoms in dementia, there is little evidence-base to support this practice. Typical antipsychotic drugs are known only to be modestly effective and can have potentially serious side-effects especially in older adults. There have been many studies on the overuse of antipsychotic medication, especially in people with dementia and those living in nursing homes. These drugs are associated with extrapyramidal side effects, increased risk of falling, excessive sedation and accelerated cognitive decline. Several trials have also shown that these drugs can be safely discontinued in many of these situations.
It is now recommended that patients have appropriate assessment and investigation leading to a definite diagnosis of dementia. This gives the advantage of offering the person with dementia specific treatment and the ability to plan future care and needs. The anti-dementia drugs such as the acetylcholinesterase inhibitors (donepezil, rivastigmine and galantamine) and the NMDA antagonist memantine have all been shown to confer benefit in improving behaviour and psychiatric symptoms of dementia. Studies have shown that these drugs also reduce the need for prescribing antipsychotic medication. Depression may co-exist in a person with dementia and is potentially treatable. A trial of antidepressant medication such as a selective serotonin reuptake inhibitor is warranted.
Experience has shown that an underlying physical cause may well be the reason for a sudden worsening in behavioural and psychological symptoms of dementia. The family doctor is in an ideal position to identify whether there is a physical component which obviously calls for the management of the underlying cause first. A patient’s disturbed sleep pattern could be related to pain from arthritis and which may well respond to simple analgesia rather than prescribing a hypnotic drug. The original complaint may be ‘urinary incontinence’, but a cautious doctor would examine and exclude the possibility of urinary retention with overflow, a urinary tract infection or polyuria secondary to diuretics or secondary to uncontrolled diabetes. A review of the patient’s medication may help to identify drugs that may worsen confusion such as cimetidine, digoxin, anticholinergic and antihistaminic medication, hypnotics and psychotropic drugs.
Over the last decade, there has been a growing interest in the non-pharmacological management of dementia. A person centred philosophy to care is being recommended, with an emphasis on maintaining respect and dignity, and encouraging an enjoyable and active life for people with dementia. Recreational and social activities such as those provided in community day centres help to maintain stimulation and social interaction. Aromatherapy with lemon balm or lavender oil have been studied and shown to have a significant effect on agitation. Music and drama therapy have also been used to help improve the psychological and physical wellbeing of people with dementia. Environmental interventions to improve the design and layout of home environments for people with dementia maximize the potentials and functional abilities of patients and increase their safety especially if living on their own. Over recent years, technological devices are increasingly being developed and installed to assist safety living in the community.
Education of caregivers plays an important part in the proper management of these symptoms. Information on how to deal with these Alzheimer’s related behaviours is now available from Alzheimer Associations around the globe and can be downloaded from their websites for free. The key is to understand that these behaviours are in most cases resulting from an altered sense of reality that people with dementia are experiencing. This makes them prone to feeling afraid whenever they cannot understand clearly what is happening around them. Psychiatric symptoms such as hallucinations and delusions may be very frightening experiences to patients. In most cases, one can identify a trigger – a situation which started the behaviour. If this can be dealt with beforehand, it may well solve the problem without resorting to medication. Sometimes an environmental cause can be identified which is causing the person to become upset. Some people with dementia may perceive their own image in a mirror as being an intruder trying to attack them. This problem can be easily solved by covering the mirror with cardboard. Relatives are instructed not to start any unnecessary arguments and are told not to challenge a person with a delusion or who is experiencing a hallucination. Redirecting and distracting the person with dementia to another activity works much better than confrontation. Relatives and carers of people with dementia require much support and counseling so that they can come to terms with such challenging behaviours. Socially inappropriate behaviour may be very upsetting to caregivers who will need reassurance and advice on how to deal with the situation. Carer support also involves admitting the patient for a period of respite care in a hospital or nursing home setting which will also serve as an opportunity for continuing assessment.
The article has drawn attention to the current trends in improving the care of people with dementia. It calls primarily for an appropriate evaluation of the situation in all instances and for an effort to treat behavioural symptoms positively through the use of non-pharmacologic approaches, education and understanding.
Alzheimer’s Society. Policy Position Paper – Prescribing of Neuroleptic and Antipsychotic Drugs. Available from: http://www.alzheimers.org.uk/News_and_campaigns/Policy_Watch/neuroleptics.htm
Burns A, Byrne J, Ballard C, Holmes C. Sensory Stimulation in Dementia. BMJ 2002; 325:1312-3.
Committee on Safety of Medicines. Atypical antipsychotic drugs and stroke. Press Release. 2004.
Lee P, Gill SS, Freedman M et al. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. BMJ 2004; 329:75-9.
Royal College of Psychiatrics Faculty for the Psychiatry of Old Age. Atypical antipsychotics and behavioural and psychiatric symptoms of dementia – Prescribing Update For Old Age Psychiatrists. Available from: http://www.rcpsych.ac.uk/college/faculty/oap/BPSD.pdf
Sink KM, Holden KF, Yaffe K. Pharmacological Treatment of the Neuropsychiatric Symptoms of Dementia. A review of evidence. JAMA 2005; 293:596-608.