Management guidelines for behavioural and psychotic symptoms in persons with dementia — A review article

This paper is a review article which has systematically gathered contemporary evidence, the best practice guidelines for the management, treatment of behavioural and psychological symptoms of dementia and the various approaches including pharmacological and non-pharmacological approaches. It sets out to outline the various types of behaviour in different subtypes of dementia and a practical approach for clinicians in managing these behaviours.


INTRODUCTION
Behavioural and Psychological Symptoms of Dementia (BPSD) is a common but often a confusing and challenging area in dementia care and it consists of a variety of different symptoms.
More than 90% of people with dementia will experience BPSD as a part of their illness and nearly two thirds of people living in care homes are experiencing these symptoms at any time.
This paper seeks to review the common types of BPSD and gives a review of the evidence based on practice approaches to manage these challenging behaviours in clinical practice with relevance to the mental health act and practice in the United Kingdom.

MANAGEMENT OF BPSD
Mild to moderate BPSD (without imminent risk of ag-gression/violence or severe distress to themselves or others) often has potentially reversible causes or can be managed in their current care setting given the appropriate social and non pharmacological interactions including environmental manipulation or if identifiable medical causes could be found and treated.Most BPSD of this type will resolve itself within 4 weeks without resort to immediate pharmacological treatment.Please refer to the Alzheimers society guidance (optimising treatment and care for behavioural and psychological symptoms of dementia) for more detailed information on the range of non pharmacological treatment.
Delirium must be excluded based on the clinical picture of a rapid (<1 week) change with decreased attention and often a fluctuant picture.Illusions/hallucinations are a common presentation.The CAMS (confusion assessment method) is a useful adjunct in determining this.
If found follow the NICE guidelines for delirium (1).Contributory physical problems such as dehydration, pain, infection, electrolyte imbalances, constipation, side effects of polypharmacy must be considered and treated appropriately, and if necessary admission to an acute hospital should be considered.
Severe BPSD (with significant distress to the individual, carer and/or aggression that results in significant risk to themselves and others).
Medication should be considered if: 1) Non-pharmacological approaches have failed and the risk to the patient or others is high enough to consider treatment whilst non pharmacological approaches are still tried.
2) If it is required in order to implement assessments and investigations of delirium such as physical examination, BP pulse and blood screen investigations, by primary or secondary care.

LEGAL FRAMEWORK
Many individuals at this stage may not have the capacity to consent to treatment for their BPSD and therefore relevance to the Mental Capacity Act, their carer and or IMCA and careful documentation for the indications of the use of medication must be documented prior to initiation of pharmacological treatment and on reviews.There may also be the need to use covert medication which should include relevance to policies of that setting.
In particularly treatment resistant and aggressive patients it may be necessary to admit to an appropriate psychiatric unit for ongoing assessment and treatment of their behaviours

SUBTYPES OF DEMENTIA
The following Tables 1-6 will help guide pharmacological approaches to (mod to severe) BPSD and the main different subtypes of BPSD.

Vascular Dementia/Frontotemporal Dementia
There is little evidence base for the treatment of vascular or stoke relate dementia or aggression associated with frontotemporal dementia.The use of anti-cholinesterase inhibitors would be outside the license indications and may even exacerbate aggression or psychosis in these conditions.There is some limited evidence to suggest that memantine has some effects on psychosis and agitation in these dementias, however, it is again outside of its licensing arrangements.However the diagnosis of vascular dementia is not stable and patients often develop signs of Alzheimer's on top of vascular problems.The risk of CVA is higher with anti-psychotics in these dementias.

Other Types of Behavior
There is no evidence medication helps for vocalisations (shouting, screaming, signing etc.) unless as part of a depressive syndrome.
There is no well evidenced based treatment for physical sexual disinhibition.If either one or both parties do not have capacity it is necessary to make a referral to the local Vulnerable Adults department.Often testosterone lowering medications such as cimetidine or finasteride are used.It is good practice to discuss with secondary care before treatment and this should be used under the rubric of the Mental Capacity Act or the Mental Health Act (England and Wales 2007).
All treatments must be time limited with stop dates considered at time of initiation.
Lorazepam may be used for short term adjunct in managing anxiety, agitation and aggression, however, it has limited evidence base and over longer term use i.e. >4 weeks is associated with greater risk of tachyphylaxis and falls.
It has little specific evidence base in people with dementia but is often used for anxiety/agitation/aggression.Tolerance can occur and it is not advised to use longer than 4 weeks.1/2 mg is the usual dose from once to maximum 4 times a day.Its use can be associated with worsening cognition and falls.There is occasionally a paradoxical disinhibiton.Diazepam has an unpredictable and often longer half life in older people and is not recommended.

Licensing Issues
Risperidone has a licence for in Alzheimer's disease for up to 6 weeks.All other antipsychotic use would be out of the licence.
Rivastigmine liquid and capsules have a license in dementia in Parkinson's disease Any treatment should be with the involvement of the patient or under the mental capacity act if the patient dose not has capacity to consent to treatment including as far as reasonably practical to speak to the carer or nearest relative before administering treatment.

Antipsychotics
There is a class effect danger of an increased risk of C.V.A (~3 xs) and longer term use increases mortality rate (~2 xs).The risk is higher if there are other cardio-vascular risk factors including existing evidence of stroke or a vascular component to the dementia.
Quetiapine [4] has been shown to be the least effective of the antipsyhotics in ameliorating BPSD and worsening cogntion and should not be used as an adjunct to treating psychosis or aggression in dementia.

Mood Stabilisers
There is some modest effect to support the use of carbamazepine [5] in the management of agitation.Please note there is a high incidence of side effects such as rash and ataxia.It should be started at a low dose such as 50 mg bd and titrated from 50 mg bd to a maximum maintenance dose of 200 mg bd.There is insufficient evidence to support the use of other mood stabilisers such as Sodium Valproate.

Cholinesterase Inhibitors
If patients are already on this treatment consideration should be given to reduce the dose if it is felt over alertness is promoting the BPSD.Donepezil, galantamine, rivastigmine and memantine can currently only be initiated in secondary care in most NHS facilities.

Hypnotics
In general the use of these drugs should not be promoted in the management of BPSD or insomnia, and where practical sleep hygiene techniques such as the promotion of activities and reduced caffeine intake should be the primary course of treatment [6].There is a greater incidence of falls, worsening cognition and tolerance over a longer period of time Z drugs (zopiclone and zolpidem): note tolerance is high and the NNT after 2 weeks is over 20, so recommended as short term treatment up to 2 weeks, then stop and restart if successful for a further 2 weeks, stop and so on.

CONCLUSIONS
The area of behavioural and psychological symptoms of dementia (BPSD) is often a confusing and challenging clinical conundrum and can cause significant distress in both patients and relatives.We set out a logical and practical approach to delineate the different types of behaviour and use a systematic approach to help clinicians manage BPSD in their patients This article summarises the best clinical approaches using both an evidence base and national guidelines from clinical experience for dealing with behavioural and psychological symptoms of dementia (BPSD) in the most common subtypes of dementia.

for depression • Carbamazepine is associated with rashes and ataxia if these symptoms occur discontinueTable 4 .
Lewy body dementia (management of depression).

Table 5 .
Lewy body dementia (management of psychosis and aggression).

Table 6 .
The evidence and cost effectiveness for the different psychotropic treatments.(a) Alzheimer's/Mixed dementia; (b) Dementia with Lewy bodies or dementia in Parkinson's disease.