BPSD - Behavioural and Psychological effects of Dementia
70%
| Question | Options | Pre-response | Reading | Final |
|---|---|---|---|---|
| Licensed for vascular dementia | Donepezil Galantamine Memantine Rivastigmine None of the above |
None | None | None |
| On admission BPSD carry out | Rule out and treat co-mobidities pain and infection Encourage family or carers to bring in familiar objects Move patient to side room away from noise and distractions Sit down and create a "getting to know you" pack Provide orientation aids boards and clocks |
Rule out pain/infection | Rule out constipation/pain/infection | Rule out constipation/pain/infection |
| Nice guidelines (NG 97, 2018) state antipsychotics for (i)_____ BPSD. Review every (ii)_____ weeks | Mild, six Mild, twelve Mild to moderate, six Mild to moderate, twelve Severe, Six |
Severe, Six | Severe, Six | Severe, Six |
| Correct about BPSD | Are uncommon Often caused by inappropriate use of medication BPSD can impair QoL BPDS is not a valid reason for admission to an acute mental health unit or acute medical ward |
Impair QoL | Impair QoL | |
| Correct about Alzheimer's | Commonest dementia causing 50% of cases Family Hx is not associated with risk Prognosis from diagnosis is 10-15 years Rapid onset and fluctuating course Infarction/extensive white matter lesions on CT/MRI can help distinguish AD |
Rapid Onset | Most common | Most common |
| Antipsychotics are cautioned by MHRA becuase | Cause cognitive impairment Renal dysfunction can increase toxicity Hepatic dysfunction can increase toxicity Increased risk of cerebrovascular events Increased risk of falls |
Falls | Cereborvascular events | Cerebrovascular |
| Which should be avoided in dementia | Amlodipine Paracetamol Procyclidine Senna Simvastatin |
Procyclidine | Procyclidine | Procyclidine |
| After psychosocial models, Short term management of challenging behaviour using which | Diazepam Haloperidol Olanzapine Promethazine Risperidone |
Olanzapine | Risperidone | Risperidone |
| Correct NICE recommendation on anti-dementia treatment duration | As long as patient accepts up to 12 months continue long term only if having worthwhile effect on cognitive, functional or behavioural symptoms |
Worthwhile effect | Worthwhile effect | |
| Dementia with Lewy Bodies statements | Parkinsonism is drug-induced Level of cognitive impairment varies little through the day Difficult to distinguish from Alzheimers Patient can become acutely worse if given antipsychotic Visual hallucinations uncommon |
Acutely worse if given antipsychotic | Acutely worse with antipsychotic | Acutely worse with antipsychotic |
- Describe the common presentations and causes of dementia.
- Describe how to assess a patient for suspected dementia, and know which investigations are relevant.
- Identify which patients require referral to specialist services, and what these services will offer.
- Describe rational treatment choices to slow the progression of dementia, including National Institute for Health and Care Excellence (NICE) guidance on when these treatments should be prescribed.
- Choose suitable treatments for the behavioural and psychological symptoms of dementia (BPSD), including assessing the risk of the harm and likelihood of benefit of antipsychotic agents.
- Psychiatric problems, including dementia, depression and delirium, are common in older adults.
- Dementia of the Alzheimer type accounts for over half of all dementia diagnoses (62%), with vascular (17%) and Lewy body (4%) dementias also common (Dementia UK Update, 2014).
- Mixed dementia accounts for 10% of cases (Dementia UK Update, 2014).
- Older age is the greatest risk factor for dementia but early-onset dementia does occur, albeit far less frequently. 'Early onset' refers to those affected aged 65 or younger in contrast to 'late onset'.
- Access to medicines to help manage the symptoms of dementia has increased, although there are still restrictions on their use in the NHS as outlined in NICE guidance.
- Research confirms that up to 90% of people with dementia may experience Behavioural and Psychological Symptoms of Dementia [BPSD] during the course of their illness.
- Certain antipsychotics may be effective in the short-term for managing some BPSD, such as aggression. However, these treatments may put the patient at risk of other complications longer term (e.g. cerebrovascular events). It is important to understand and address situations that may cause BPSD, to avoid unnecessary medication.
- World Health Organization published a guideline on 'risk reduction of cognitive decline and dementia'
- NICE guidance
- Taylor D, Feetam CL Aston University. Postgraduate Certificate Programme in Psychiatric Therapeutics by Distance Learning. Module 6. The Dementias and Related Disorders. December 2011 (13th Edition).
- Ballard CG, Gauthier S, Cummings JL, et al. (2009). Management of agitation and aggression associated with Alzheimer disease. Nat Rev Neurosci. 5; 245-255.
- Ballard C, Hanney ML, Theodoulou M et al. (2009). The dementia antipsychotic withdrawal trial (DART-AD); long-term follow up of a randomised placebo-controlled trial. Lancet Neurology. 8; 151-157.
- Banerjee S. (2009). The use of antipsychotic medication for people with dementia: Time for action. A report for the Minister of State for Care Services.
- Brodaty H and Moore CM. (1997). The Clock Drawing Test for dementia of the Alzheimer's type: a comparison of three scoring methods in a memory disorders clinic. International Journal of Geriatric Psychiatry. 12; 619-627.
- Folstein MF, Folstein SE and McHugh PR. (1975). 'Mini-Mental State': a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research. 12; 189-198.
- Jorm AF. (1994). A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and cross-validation. Psychol Med. 24; 145-153.
- Loy CT, Schofield PR, Turner AM et al. (2014). Genetics of dementia. The Lancet. 383; 828-840.
- McKeith IG, Dickson DW, Lowe J et al. (2005). Diagnosis and management of dementia with Lewy bodies: third report of the DLB consortium. Neurology. 65; 120; 1268-1272.
- Nasreddine ZS, Phillips NA, Bédirian V et al. (2005). The Montreal Cognitive Assessment (MoCA): A Brief Screening Tool for Mild Cognitive Impairment. Journal of the American Geriatrics Society. 53; 695-699.
- National Institute for Health and Care Excellence (NICE) (2018). Dementia: assessment, management and support for people living with dementia and their carers. (Online). Available at: https://www.nice.org.uk/guidance/ng97
- Qureshi K and Hodgkinson M. (1974). Evaluation of a 10 question mental test of the institutionalized elderly. Age & Ageing. 3; 152-157.
- Robinson L, Tang E and Taylor JP. (2015). Dementia: timely diagnosis and early intervention. BMJ. 350; 3029.
- World Health Organization (2019). Risk reduction of cognitive decline and dementia. (Online). Available at: https://www.who.int/mental_health/neurology/dementia/guidelines_risk_reduction/en/
progressive decline in cognitive function that arises from a degenerative organic brain disease.
Three aspects to early management are:
- Identifying people with dementia: be vigilant to the possibility of dementia and when suspicious, ask the patient and accompanying close contacts if the patient has experienced any memory problems in the last 12 months.
- Assessing people with dementia: if there is evidence to suggest a problem with memory, carry out a brief cognitive assessment (e.g. General Practitioner assessment of Cognition (GPCOG). or Abbreviated Mental Test ).
- Referring on for advice: know when to refer the patient for further support, either to a liaison team or memory clinic.
Dementia is a term for a syndrome characterised by acquired global impairment of higher mental functions without impairment of consciousness. The key mental functions that are impaired are:
- Cognition: memory impairment, speech and language problems, difficulty carrying out complex actions (apraxia) such as dressing, or problems with somatosensory integration (e.g. differentiating between a toilet and waste bin).
- Neuropsychiatric features: character or behavioural changes.
- Activities of daily living: washing, dressing, cooking etc.
Delirium is a term for a characteristic acquired syndrome of acute onset. Review the ICD10 criteria for delirum here.
It is often referred to as an 'acute confusional state'. Its rapid onset, fluctuating course, and transience distinguish it from dementia. Tools like the Confusion Assessment Method (CAM) help identify it. CAM asks you to decide if acute onset, fluctuating course, inattention, disorganised thinking and altered consciousness are present.
| Risk Factors | Precipitants |
|---|---|
| Acute illness Older age Pre-existing dementia Sensory impairment |
Medicines: especially anticholinergics, benzodiazepines, anti-parkinsonism agents Infection: especially respiratory tract and urinary tract infections Metabolic problems: such as hypothermia, dehydration and acute kidney injury Substance misuse: especially acute alcohol withdrawal Direct brain insult: for example, post-seizure, head injury |
| Core Features | Biological Symptoms |
|---|---|
| Low mood. Reduced energy levels. Reduced enjoyment. |
Diurnal variation of mood. Reduced/increased appetite. Reduced concentration. Retardation or agitation. Waking early/hypersomnia. Weight loss/gain. |
| Alzheimers | Vascular Dementia | Lewy Body Dementia | Fronto-Temporal Dementia |
|---|---|---|---|
| Alzheimer’s Disease (AD) is the most common type of dementia, causing at least half of all cases. Neurotoxicity is thought to be caused by extracellular beta amyloid plaques, and intracellular neurofibrillary tangles comprising tau protein. Neuroimaging will reveal no space occupying lesion, and may show generalised cortical atrophy and (highly suggestive) thinning of medial temporal lobe and hippocampi. | Pure Vascular Dementia (VaD) accounts for about 17% of dementia cases, while mixed dementia (a mixture of Alzheimer's and VaD) causes a further 10% of cases. Essentially, VaD is a dementia caused by cerebrovascular disease. At post-mortem, multiple infarctions and/or extensive small vessel disease will be found. | Dementia, in which attention, executive function and visuospatial deficits may well be especially prominent and occur early. | Group of conditions which cause predominantly frontal lobe and temporal lobe degeneration. Approximately 2% of all cases of dementia are due to FTD but it is most prevalent in people aged 45 to 65 years where it is the second commonest cause of dementia after Alzheimer's. Some cases are associated with motor neurone disease, but the most common type is Pick's disease. Pick's disease often starts in the 6th decade, is more likely among females, and has a strong family history. Time to death is typically 6-8 years. |
| Neuropsychological assessment will typically show diffuse deficits in short-term memory, impairment of language and, as the condition progresses, impairment of judgment, visuospatial ability and in sustaining attention. Onset of the condition is typically insidious and delays to diagnosis are therefore common. Prognosis is between 5-10 years from diagnosis to death. On average, a family history doubles the risk of someone developing Alzheimer's over their lifetime (Loy et al, 2013). |
Abrupt onset. Hypertension. History of stroke. CT or MRI evidence of infarction and/or extensive periventricular white matter lesions. |
In LBD the onset of dementia is usually within one year of the onset of parkinsonism. A delayed onset of dementia beyond one year of onset of parkinsonism is suspicious for Parkinson’s Disease dementia (PDD). ‘Lilliputian’ visual hallucinations are formed of people and objects that are much smaller than their real life counterparts. This type of vivid hallucination is common in LBD. A positive DaT scan (DA receptor uptake), acute fluctuation in consciousness, and sensitivity to anti-psychotic medication are all in keeping with LBD. Fluctuating cognition. Visual hallucinations. REM sleep behaviour disorder. Parkinsonism. |
Disinhibition. Early loss of social awareness and insight. Emotional change including impulsivity, elation, anxiety, or emotional unconcern. Excessive exploration of objects or the environment (spatial abilities are preserved). Hyperorality. Inertia . Insidious onset, slow progression. Rigid, inflexible cognitive style. Speech deficits, for example poor verbal output, echolalia, concrete responses and perseveration. |
- Activities of daily living: washing, cooking, managing finances, and dressing
- Cognition: memory impairment, speech difficulty, problems carrying out complex actions or understanding sensory information
- Neuropsychiatric features: changes in character or behaviour
- Does the person repeat themselves over and over?
- Does the person get mixed up over days and dates?
- Does the person forget to take their tablets?
- Does the person struggle with bills and money?
- Can the person wash, dress, cook?
- Does the person experience problems finding the right words?
- General Practitioner Assessment of Cognition (GPCOG)
- Abbreviated Mental Test Score (AMTS)
- Clock-drawing
- Mini-Mental State Examination (MMSE)
- Montreal Cognitive Assessment (MoCA)
| Addenbrookes Cognitive Assessment-III (ACE-III) | The Cambridge Assessment of Memory and Cognition [CAMCOG] |
|---|---|
| The ACE-III was developed as a screening test for dementia, which unlike the MMSE, would rely more on executive (e.g. judgement/abstraction) than verbal abilities. ACE-III covers five cognitive domains (attention, memory, fluency, language and visuospatial processing). It takes 15-20 minutes to complete. It is very reliable and improves the accuracy of the diagnosis. | This well established assessment covers many cognitive functions including orientation, memory, language and attention. It takes between 25 and 40 minutes to complete. Conventional cut-offs of 79-80 (from 105) identify possible/probable dementia. It includes questions to give you an MMSE score. |
- Every patient with suspected dementia should have structural imaging, either a CT or MRI scan of the brain.
- The purpose is to rule out structural brain lesions like tumours, infarction, haematomas, or normal pressure hydrocephalus.
- Used to increase precision of diagnoses of Alzheimer's dementia.
- In particular, confirmed thinning of medial temporal lobes and hippocampi increase accuracy of Alzheimer's dementia diagnosis.
- Specialist Imaging
- SPECT scanning can help distinguish between Alzheimer's, vascular and fronto-temporal dementias. It is recommended when fronto-temporal dementia is a differential diagnosis.
- DaTscan (Ioflupane I 123 injection) imaging can help distinguish Parkinsonian syndromes from Alzheimer's.
Include functional impact with the referral
- Borderline cases where the diagnosis is unclear.
- If the management of dementia is complicated by depression, anxiety, psychosis or refractory BPSD. Patients with delirium who are physically unwell sometimes require referral to the Emergency Department or acute medicine to identify and treat organic causes.
- If local protocols mean treatment can only be obtained from specialist clinics.
- If the patient or their family/carer are dissatisfied.
- If you feel that specialist assessments like neuropsychological assessments or functional imaging are needed for diagnosis.
- If specialist services can open up care pathways like carer support, cognitive interventions, and research opportunities.
- Where diagnostic decision may affect risk decisions (e.g. antipsychotic induced risk of stroke or death).
Mild to moderately severe Alzheimer's disease
| Drug | Class | Indications |
|---|---|---|
| Donepezil | Acetylcholinesterase Inhibitors | Mild to moderately severe Alzheimer's disease |
| Galantamine | Acetylcholinesterase Inhibitors | Mild to moderately severe Alzheimer's disease |
| Rivastigmine | Acetylcholinesterase Inhibitors | Mild to moderately severe Alzheimer's disease Mild to moderate Parkinson's disease dementia |
| Memantine | NMDA partial agonist | Moderate to severe Alzheimer's disease |
- There is evidence to offer patients with Lewy-body dementia a trial of an acetylcholinesterase inhibitor. NICE guidelines (NG 97, 2018) recommend offering donepezil or rivastigmine first-line to patients with mild to moderate dementia with Lewy bodies. Galantamine should only be considered for mild to moderate dementia with Lewy bodies if donepezil or rivastigmine are not tolerated. Donepezil or rivastigmine can also be considered in patients with severe dementia with Lewy bodies.
- Evidence is not strong enough to support a licence for use in vascular dementia. However many patients in clinical practice have both Alzheimer's disease and cerebrovascular pathology, so clinicians will commonly treat patients with mixed Alzheimer's and vascular pathology. NICE guidelines (NG 97, 2018) recommend considering an acetylchlinesterase inhibitor if they have ‘suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies’.
- There is no evidence to support the prescription of acetylcholinesterase inhibitors in fronto-temporal dementia. Of all the options fronto-temporal dementia is least likely to co-exist with Alzheimer's disease. In clinical practice acetylcholinesterase inhibitors are almost never prescribed for patients with fronto-temporal dementia.
- Treatment should only be initiated on the advice of a specialist (e.g. psychiatrist, geriatrician) and the carers' views should be sought prior to initiation.
- Assessment of the severity of Alzheimer's disease should not rely purely on cognitive measures (such as the MMSE).
- Acetylcholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are recommended as monotherapy options for the management of mild to moderate Alzheimer's disease.
- Memantine monotherapy is recommended as an option for severe Alzheimer's disease and for people with moderate Alzheimer's disease unable to take acetylcholinesterase inhibitors.
- In patients with an established diagnosis of Alzheimer's disease already taking a acetylcholinesterase inhibitor:
- Consider adding memantine in addition to acetylcholinesterase inhibitor in moderate disease.
- Offer memantine in addition to acetylcholinesterase inhibitor in severe disease (NICE NG 97).
- Acetylcholinesterase inhibitors and memantine are not recommended for patients with vascular dementia or mild cognitive impairment except as part of properly constructed clinical studies. They may be used in patients with mixed Alzheimer's and vascular dementia.
| Antimuscarinic agents | Hypnotics and anxiolytics |
|---|---|
| These include medicines whose pharmacological action depends on antimuscarinic effects (e.g. oxybutynin for bladder instability, procyclidine for parkinsonism) or those that have antimuscarinic adverse effects (e.g. tricyclic antidepressants for depression or pain as well as many antipsychotics). These have all been shown to affect cognition, worsening cognitive performance in the short- and long-term. | Sedatives such as benzodiazepines undoubtedly affect cognition in dementia, and may be associated with postural instability. Those with a longer half-life, or active metabolites, such as diazepam, are more likely to accumulate and have a greater adverse effect on cognition, compared to those with a shorter half-life like lorazepam which has no active metabolites. |
They are a result of complex interplay between the illness, the environment, interaction with others, physical health, and medicines. Although these symptoms can often remit spontaneously, they can also be persistent and severe, causing considerable distress to patients and carers, significantly impairing of quality of life and increasing risk for both the sufferer and other people around them. Unmanageable BPSD is the most common reason for carer stress and institutionalisation of the person with dementia.
- Agitation, resulting in aggression
- Anxiety
- Delusions
- Depression
- Disinhibition
- Elation Apathy
- Hallucinations
- Irritability
- Paranoia
- Persistent vocalisation (screaming)
- Psychosis
- Reduced appetite
- Repeated questioning
- Sleep disturbance
- Wandering (moving and walking about)
| Medical Review | Person Centred Care | Physical Environment |
|---|---|---|
| Carry out a full medical review (including medicines) to rule out and address co-morbid conditions such as depression, infection or physical discomfort. Pain especially can be a major trigger for agitation and aggression - prescribing paracetamol has been shown to reduce BPSD. Other key triggers include dehydration, constipation and malnourishment. |
This describes a care approach different to usual NHS task-centred care. | |
It is designed to encourage healthcare professionals to value people with dementia, and involves trying to understand their experience of the world, adjusting the environment to suit them, and understanding their personal history. |
||
For this approach to work well, it requires all staff to be trained who come into contact with the patient. In primary care some basic elements which can help include: A 'getting to know me' pack recording patient's history, contacts, likes and dislikes (see the 'This is Me' document from the Alzheimer's Society) . Communication tips, such as not giving instructions, and diverting rather than correcting. Focus on and respond to the emotion the person is experiencing rather than the behaviour. |
Before a patient is taken to a new environment e.g. care home, the following advice should be given: Encourage family or carers to bring in familiar objects. Ensure hearing aids and spectacles are worn. Provide orientation aids like boards and clocks. Minimise excessive noise and distraction. Consistent carers can help the patient, although this is something that might be difficult to control. Use positive communication techniques to reduce stress; make eye contact and smile and introduce yourself each time. Remember as a GP you may offer a consistent and familiar face. |
all antipsychotics should be assumed to carry an increased risk of cerebrovascular events when they are used in elderly patients with behavioural disturbances in dementia. Only offer antipsychotics for people living with dementia who are:
- ‘at risk of harming themselves or others, or
- ‘experiencing agitation, hallucinations or delusions that are causing them severe distress’ (NICE NG 97).
Risperidone has an evidence base to support its use in BPSD and is the only antipsychotic licensed for this indication. However be aware that:
- The licensed dose for this indication is much lower than for other indications (initially 250 micrograms twice a day, up to a maximum of 1 mg twice a day).
- It is licensed for no more than 6 weeks treatment in patients experiencing persistent aggression in Alzheimer's dementia (BNF, 2018).
- It may be slightly more effective in treatment of aggressive than non-aggressive agitation.