BPSD
Introduction to Behavioral and Psychological Symptoms of Dementia

What does "BPSD" mean? "BPSD" stands for behavioral and psychological symptoms of dementia, a phrase coined by participants at an international consensus conference on behavioral disturbances of dementia convened by the IPA Task Force on BPSD, March 31 - April 2, 1996, in Lansdowne, Virginia, USA, in the Washington DC area. Previously, clinicians and researchers had used the term behavioral disturbances of dementia but this proved difficult to define and was seen as hampering efforts to reach a better understanding of this aspect of dementia given the heterogeneity of interpretation it inspired. 

What are BPSD? The Behavioral And Psychological Symptoms of Dementia are defined as: 

"Symptoms of disturbed perception, thought content, mood, behavior frequently occurring in patients with dementia".

How common are BPSD? Approximately 83% of demented patients demonstrate psychopathology: 60% have delusions, 20% hallucinations, 33% verbal outbursts, 35% anxiety and 40% have affective symptoms. Some 13% of demented patients show physical aggression and as many as 64% of nursing home patients have significant behavioral problems. The most common BPSD resulting in institutionalization are paranoia and aggressive behavior. 

What is the impact of BPSD? Behavioral symptoms that require continual supervision or involve aggressive acts are more strongly associated with caregiver burden than is the need for physical assistance with activities of daily living. Physical aggression against caregivers is a known risk factor for abuse of the care recipient by the caregiver. Nonaggressive behavioral symptoms can increase the distress of the caregiver because the demands they make on the caregiver's time and attention are less predictable than those of routine daily care. Psychological symptoms (or symptoms of a co-existing mental illness) such as depressive complaints or paranoid accusations are also often viewed by caregivers as 'behavioral problems'. 

Ideally, one would want to maintain elderly patients with dementia in their own homes, but the burden of providing care in this setting can overwhelm families. The difficulties of providing direct care and assistance for someone with physical and cognitive limitations is associated with mood disturbances, more frequent visits to the doctor and increased use of prescription drugs among caregivers. Increased self-reports of poor health and evidence of immunosuppression among some groups of caregivers are additional indicators that physical health risks are associated with the caregiver role. Poor health, financial strain and the fear of being trapped in a "caring" role are significant predictors of caregiver acceptance of the placement of an ill relative in a nursing home. 

How are BPSD managed? The first stage in the management of BPSD is a proper assessment of the symptoms that are causing distress. A simple yet effective approach is summarized in the following steps: 

1. Characterize the behavior precisely with special attention to the circumstances under which it occurs, when it started and whether onset was gradual or sudden. 

2. If the behavior appears inappropriate, consider whether there is an underlying goal (e.g. exit-seeking) or misperception (e.g. misperceiving the corner of a room as a urinal, or another person's bed as one's own). 

3. Review the patient's psychiatric history, social history and premorbid personality.

4. Review the medication list with special attention to changes around the time the behavior started and to drugs known to cause agitation, apathy or confusion. 

5. Inquire about life events and the quality of premorbid relationships between carer and patient. 

6. Examine the patient with attention to changes in mental status from baseline. Look for signs of painful or uncomfortable physical conditions that may be producing agitation or aggressiveness by increasing physical arousal. If possible, ask the patient to explain the symptom and give an account of his general health and living conditions. 

7. Develop two sets of hypotheses on which to base treatment.

• Diagnostic: includes considerations of concurrent mental illness, delirium, painful or uncomfortable physical conditions and drug side effect
• Mechanistic: describes mechanisms of behavior and includes neurological interpersonal or environmental triggers of behavior, with possible goal or motives for the behavior

Treatment approaches: drug treatment. When a specific co-existing mental disorder other than the dementia is identified, the appropriate treatment for that disorder is given, e.g. an antipsychotic for frank psychosis or an antidepressant for depressive symptoms. If the patient has symptoms of a mental disorder but does not meet diagnostic criteria for a complete syndrome, appropriate drug treatment may still be indicated if it is likely that the subsyndromal mental disturbance has caused the BPSD. Drug treatment is usually reserved for patients with moderate to severe disturbance and where non-pharmacological interventions have failed. If there is no mental disorder other than dementia, the role of drug therapy is less well established. 

Use of traditional antipsychotic medications to treat symptoms of agitation has undergone limited study. A meta-analysis of seven placebo-controlled studies showed that treatment with antipsychotic medications led to improvement in 59.5% of patients whereas treatment with placebo led to improvement in only 40%. Patients with hallucinations and paranoid delusions are more likely to respond to drug therapy. However, care must be taken in the prescription of antipsychotic medications, particularly the conventional antipsychotics, as patients with dementia are more sensitive to extrapyramidal, anti-cholinergic side effects than the general population. 

Although not thoroughly tested in clinical trials, b-Adrenergic blockers, antiepileptic drugs, and drugs that modify serotonergic transmission (reuptake inhibitors and partial agonists) have all been reported as helpful in treating agitation in dementia. The use of these drugs for patients with behavioral symptoms unresponsive to nonpharmacologic treatments is best undertaken as a trial of predetermined duration, with measurable outcomes on which the decision to continue treatment will be based. 

Case studies and/or an occasional trial suggest that serotonergic drugs (eg, trazodone, nefazodone, sertraline, buspirone) might be tried when irritability is a prominent symptom, and antiepileptic drugs (eg, valproic acid, carbamazepine) when frequent mood fluctuations or sudden spontaneous attacks of agitation are the problems. 

Case reports suggest that there may be a role for dopamine-agonist drugs or direct stimulants such as methylphenidate in the treatment of apathy. However, controlled clinical trials remain to be done, and the best-established treatment at present is the discontinuation of drugs known to cause or aggravate lethargy or apathy. 

Treatment approaches: nonpharmacologic treatment. The past decade has seen a substantial increase in nonpharmacologic treatments for behavior disturbances in dementia, including validation therapy, reality orientation, music and movement therapies, and environmental antiwandering programs. Rigorous outcome studies are in progress but have not yet been completed. Nonpharmacologic treatments for behavioral symptoms are the distinguishing feature of dementia special care units and of specialized dementia programs within nursing facilities and adult day care centers. They appear to be of greatest utility during the early to middle stages of dementia, before the patient is physically immobilized. Expertise in nonpharmacologic therapies is claimed by several disciplines. Clinicians considering referrals to specialized facilities or programs should look for the significant involvement of a professional who is skilled in the analysis of the causes and triggers of behavioral symptoms, and for an ongoing program of training of the direct-care staff in methods for cueing appropriate behavior and diverting inappropriate behavior. A low rate of use of restraints and of antipsychotic medications is an indirect index of quality in this area. 

Nonpharmacologic therapies can address the presumed motive of a problem behavior or its environmental trigger, or they can rechannel the behavior or alter its consequences. The descriptive literature suggests that nonpharmacologic therapies may be most useful for patients with mild to moderate dementia who do not have an untreated mental disorder apart from dementia. 

Knowledge of the patient's premorbid personality and habits can inform the physician's choice of nonpharmacologic therapies. For example, a patient with a lifetime history of avoiding social interaction would be more likely to respond to an individual than to a group-based approach to teaching relaxation. Or, knowledge that a person had a troubled relationship with his mother might lead to the choice of a male nursing assistant to provide personal care. 

Treatment approaches: overcoming resistance to care. Resistance to care usually centers on ADL assistance, particularly bathing, and medication administration. Resistance to specific kinds of care is more common than generalized resistance to care, which most often reflects paranoid ideation or depression and should be treated appropriately. 

Resistance to bathing or dressing assistance may arise from patients' understandable desire to protect their privacy and their bodies from intrusion by a person whose motives they do not understand. If there is a person whose assistance is accepted, the simplest measure is to arrange for this person to provide most of the assistance needed. Those who encounter resistance should try approaching the patient more slowly, with much simpler explanation of their intentions, and maximal use of environmental cueing. For example, a person assisting with bathing would show the patient the bathtub and a towel before offering the patient assistance in taking off her clothing.