What is Behavioral and psychological symptoms of dementia (BPSD) and how can it be reduced by medical intervention?

In this Millennium, we see more people living longer and healthier lives, but this also means a rise in age related problems such as dementia. Hence it is not surprising that millions of people have dementia worldwide. It is anticipated that this is going to increase in the coming decades. Dementia is known for progressive loss of cognitive function; but what adds to the carer burden is what we call the Behavioral and psychological symptoms of dementia (BPSD). Up to 80% of patients with dementia present with BPSD at some stage of their illness. This may include psychiatric symptoms such as anxiety, depression, and psychotic features such as hallucinations and delusions, as well as behavioral issues such as agitation, aggression, disinhibition, hyper sexuality, wandering, sleeping and eating problems, and motor symptoms. Such symptoms often reduce the person’s and their family’s quality of life, thus many people have to be transitioned to residential care or nursing homes. This can also lead to prolonged hospital stays.

Psycho-social treatments for BPSD

Few psychosocial treatments have been proposed for treatment of BPSD in Alzheimer’s or Mixed vascular dementias. Pet therapy and visits might provide stimulation and social contact. Sensory enhancement measures such as hand massage, music, art, sensory modulation etc might also reduce BPSD. Volunteering and inclusion in group activities may provide social inclusion, role and purpose. Exercise programs and walks may also help. Carer education and support may also help to alleviate the effects of BPSD.

Medical treatment of BPSD

There is mounting evidence to support the use of psychotropic drugs in BPSD. Trials of varying quality and  meta-analyses now exist for various drugs in several classes. Yet, many of these drugs, such as antipsychotic medications, confer well-known risks of side effects such as increased risk of heart attacks, strokes and extrapyramidal symptoms. Some sedating medications may increase the risk of falls. Hence the risk of mortality and morbidity should be balanced out with clinical efficacy. Although, not many newer treatments have shown promise in this area, we have more robust evidence emerging about some of the well-known agents and their appropriate dosing in elderly.

Risperidone has the strongest evidence base for treatment of BPSD symptoms in Alzheimer’s or mixed dementia through several large randomized trials.As all antipsychotics, Risperidone carries cardiovascular and metabolic risks, it may have an additional risk of extrapyramidal symptoms. The lowest doses are recommended such as 0.25-0.5mg/day. Quetiapine and Aripiprazole may be considered as alternatives but the evidence for its use is weaker. Olanzapine does not have any additional advantage but has the risk of increased metabolic side effects.Carbamazepine is used in the management of aggression but its use in BPSD may be weighed against the drug interactions and risk of bone marrow suppression. Citalopram and Sertraline have evidence in management of depression and anxiety in patients with Dementia. It may not be as useful in other forms of BPSD. Treatment resistant symptoms such as mania, psychosis and severe depression in dementia may be treated with ECT (Electroconvulsive therapy).  To conclude, the medical management of dementia is complex, it is usually carried out by specialists with high levels of expertise.

At mindoc, we have the specialists who can accurately assess and communicate your treatment needs in a friendly environment. Unfortunately, we cannot offer any nursing home visits at this stage. All consultations are done face to face at the clinic, which also has wheelchair access. A referral from your GP will be required to access Medicare rebateable services.