BPSD

International Experts Reach Consensus on Definitions of Behavioral and Psychological Symptoms of Dementia 

Report on the International Consensus Conference on Behavioral Disturbances of Dementia, Washington DC, March 31-April 2, 1996

Why was a consensus sought?

Clinicians are aware that patients with dementias, including Alzheimer's disease (AD), experience psychosis, depression and behavioral symptoms over the course of illness but, until recently, such symptoms have elicited little interest or research support. Further, research has been hampered by the absence of viable measurements and scales developed for this specific population. Rigorous clinical trials have been rare and virtually non-existent in those with moderate and advanced dementias. Before 1992, only seven placebo-controlled randomly assigned, double-blind neuroleptic studies in BPSD in this population had been published and only one of these was in a nursing home setting. 

Since 1992 there has been a dramatic rise in interest corresponding to the development of over a dozen measurements and scales for the Behavioral and Psychological Symptoms of Dementia (BPSD). Between 1992 and 1997 eight clinical drug trials have been conducted or have begun. These trials have used a range of measurements and scales, several of which sometimes focused on a different combination of symptoms. Thus, the field has seen an influx of research attention while struggling to determine exactly what we are measuring and how these symptoms can be measured most effectively. 

It was against this background that the concept of holding an international consensus conference to begin establishing an operational definition for "behavioral disturbances of dementia" was born at the 7th International Psychogeriatric Association (IPA) congress in Sydney, Australia in November 1995. A high level of interest in a special symposium on "research methodological issues in evaluating behavioral disorders of dementia" that took place at the Sydney Congress indicated clearly that this matter was one of great concern to clinicians and researchers working with demented elderly patients, and the subsequent response to the Washington International Consensus Conference has borne out this perception. 

How was consensus reached?

To achieve a consensus of opinion, sixty experts in the field from 16 countries assembled in Lansdowne, Virginia, in the Washington DC area to review and discuss issues related to etiology, nosology and nomenclature, criterion validity, clinical symptoms, caregiver input and issues, cross-cultural and transitional considerations and future research directions. In preparation for the meeting, participants were provided with approximately 60 background articles representing the best available literature in the field. Participants listened to a series of 10-minute presentations over a day and half and then split into discussion groups, each with its own facilitator. The three groups then reassembled to pool their discussions and to arrive at a group consensus. The results of these discussions have been presented in a consensus statement, originally published in a special issue of International Psychogeriatrics (vol. 8, Suppl 3, 1996). As Sanford I Finkel MD says in his introduction to that issue "The statement is not meant as a final word but rather as a constructive beginning to help us clarify and define what we are studying and what we need to investigate. 

International consensus statement on BPSD

Behavioral and Psychological Symptoms of Dementia: A Consensus Statement on Current Knowledge and Implications for Research and Treatment 

Sanford I. Finkel, Jorge Costa e Silva, Gene Cohen, Sheldon Miller, and Norman Sartorious

Definition

The chief characteristics of dementia include multiple cognitive deficits and a deteriorating course. In addition to the cognitive symptoms, people with dementia have other symptoms that have been largely neglected until recently. These other symptoms have commonly been called behavioral disturbances of dementia. The participants of the conference thought that the term disturbances is too general, has many meanings, and is difficult to define. They recommended that the term behavioral disturbances be replaced by the term behavioral and psychological symptoms, defined as follows: 

Symptoms of disturbed perception, thought content, mood, or behavior that frequently occur in patients with dementia.

Symptoms

There are many ways in which behavioral and psychological and symptoms can be grouped. The participants recognized that for certain purposes it might be useful to group them into psychopathologically recognized symptom clusters (e.g., depressive syndrome, psychotic syndrome); for other purposes they might be organized by function (e.g., disorders of sleep) or by altered behavior (e.g., hitting, wandering). A simple method of grouping could be: 

• Symptoms usually and mainly assessed on the basis of interviews with patients and relatives; these symptoms include anxiety, depressive mood, hallucinations, and delusions.
• Symptoms usually identified on the basis of observation of patient behavior, including aggression, screaming, restlessness, agitation, wandering, culturally inappropriate behaviors, sexual disinhibition, hoarding, cursing, and shadowing. 

Although numerous techniques are available to assess these symptoms in a reliable manner, most of these have not been tested in more than one cultural setting. A major research task ahead will be studies leading to cross-culturally applicable instruments that will provide comparable data from different settings. 

Research

Advances in understanding BPSD depend on investigating their phenomenology, course, pathobiology and origins, social and environmental influences, and responses to treatment interventions. 

Opportunities for research on BPSD are more numerous than ever before because of new techniques and methods for the assessment of patients, as well as the availability of measurement scales specifically developed for this patient population. Research resources, however, are unevenly distributed and not available in many countries. A research infrastructure of networks of researchers and research settings needs to be created to ensure a strong and productive research program. Several proposed areas of research are listed in the conclusions. 

Treatment

There are two major groups of symptoms in dementias: symptoms of cognitive dysfunction and the behavioral and psychological symptoms. Treatments for the former have had modest effectiveness.  At present, the greatest opportunities for intervention and the alleviation of patient suffering, family burden, and societal costs are within the domain of behavioral and psychological symptoms of dementia.

Many of these symptoms are amenable to treatment by methods presently available, and current research effects hold the potential for further breakthroughs. The challenge lies in ensuring continued systematic investigation and the application of current and continually emerging knowledge and techniques in clinical practice. 

Conclusions

Participants in the Consensus Conference concluded that:

1. The Behavioral And Psychological Symptoms of Dementia (BPSD) are integral elements of the disease process and, therefore, are a legitimate concern of healthcare providers worldwide. 
2. These symptoms present severe problems to all those who interact with the patients as well as to the patients themselves, and to society and its health services. 
3. Many of the BPSD are now amenable to treatment. Such treatment will reduce the suffering of the patient, the burden on the family, and the economic cost arising in connection with dementia.
4. Research now needs to address the following areas: 
• Development of cross-culturally applicable methods for the assessment of BPSD;
• Exploration of the relationship of BPSD with respect to environments in which they occur and the underlying biological and psychological substrates;
• Longitudinal evaluation of these symptoms;
• Determination of the frequency, underlying pathogenic mechanisms, and clinical and social impact on patient, family, and society of the BPSD; and, 
• Development of a well-defined profile of treatment methods with specific reference to different types of behavioral and psychological symptoms and their response to pharmacologic and nonpharmacologic interventions.

Implications for the future

The development of the Consensus Statement on Behavioral And Psychological Symptoms of Dementia (BPSD) represents a first step towards recognizing that these are core symptoms of dementia and that it is as essential to study and treat them as it is to study and treat any other aspects of dementing disorders. It is to be hoped that by better defining BPSD, we will develop better standardized measures and scales which we can use to further study the symptom clusters and assess the outcome of our treatment interventions, all with the goal of improving the standard of care we offer to our demented elderly patients and their caregivers.