Non-pharmacological approaches must always be considered first.

Behaviours that challenge are best managed by good nursing care, the correct environment and use of 'ABC' (antecedents, behaviours and consequences) to try and identify causes and possible triggers for the presenting behaviour for example hunger or pain

For individuals with behaviours that challenge, identify and document target symptoms.

Conduct a structured assessment to:

• Explore possible reasons for the patient’s distress and
• Check for and address clinical or environmental causes. Assess whether symptoms could be a result of:
  • an underlying physical cause (including pain even without overt symptoms constipation, infection)
  • side-effects of medication
  • delirium
  • an underlying depressive illness and/or anxiety disorder

Once these have been discounted consider appropriate non-pharmacological interventions, for example environmental changes and psychosocial interventions.

Where management is not urgent or for less severe BPSD, a combination of non-pharmacological approaches are appropriate first-line treatments.

If symptoms do not resolve consider pharmacotherapy.

Pharmacological treatment is not a substitute for other approaches; techniques must always be used concurrently.

For more information on the initiation, treatment options and management of patients, see the DPT Prescribing Guideline PG14: Pharmacological Management of Severe Behavioural & Psychological Symptoms of Dementia (BPSD)

Initiation of medication for BPSD (specialist-initiated or recommended)

Document which non-pharmacological interventions have been used or offered.

The specialist should identify, quantify & document target symptoms including severity and level of distress caused to the individual, including family / carers, and set realistic treatment goals. A baseline physical monitoring assessment appropriate to the antipsychotic prescribed and a cognition assessment should be conducted, and a formal record of capacity documented.

For more information on initiation of medication, see the DPT Prescribing Guideline PG14: Pharmacological Management of Severe Behavioural & Psychological Symptoms of Dementia (BPSD)

Communication of information to families and carers

The prescriber must discuss the possible treatment options with the individual and/or family/carers, including the anticipated benefits and potential risks of treatment (in particular, cerebrovascular risk factors should be assessed and the possible increased risk of stroke/transient ischaemic attack and possible adverse effects on cognition discussed). The risks and benefits of atypical antipsychotics are described below.

Leaflets on dementia for patients, family, and carers can be found on the Alzheimer's Society website.

Recommended treatments

The expected benefits must outweigh the potential risks/side effects of medication for each individual. Pharmacological management of severe BPSD (agitation and aggression in particular) should only be considered if behaviours cause severe distress to the individual and/or there is immediate risk of harm to other patients or carers.

Antipsychotics

The choice of medication for an individual must be on the recommendation of a specialist.

Only offer antipsychotics for people living with dementia who are either:

• At risk of harming themselves or others or
• Experiencing agitation, hallucinations or delusions that are causing them severe distress

Symptoms which do not usually respond to antipsychotics include wandering, social withdrawal, shouting, pacing, touching and cognitive defects.

Dementia with Lewy bodies and Parkinson’s dementia: Antipsychotics can worsen the motor features of dementia with Lewy bodies or Parkinson’s disease dementia, and in some cases cause severe antipsychotic sensitivity reactions. For more guidance, see the advice on managing hallucinations and delusions in the NICE guideline NG71: Parkinson’s disease in adults.

The Banerjee report (2009): The use of antipsychotic medication for people with dementia summarised the risks and benefits of treating 1,000 people with BPSD with an atypical antipsychotic for around 12 weeks:

• An additional 91-200 patients with behavioural disturbance showing clinically significant improvement in symptoms
• An additional 10 deaths (Evidence suggests that risk of mortality increases over time, therefore longer term treatment may result in up to 167 additional deaths over a 2 year period
• An additional 18 cerebrovascular adverse events of which ~ 50% would be severe (Evidence from observational studies suggests increased risk of cerebrovascular adverse events may be confined to the 2-3 month period typically encompassed in RCT follow-up studies)
• No additional falls or fractures
• An additional 58-94 patients with gait disturbance

When using antipsychotics:

• Use the lowest effective dose and use them for the shortest possible time
• People with dementia with Lewy bodies and Parkinson’s dementia have increased sensitivity to antipsychotic side effects, including acute & severe physical deterioration. If an antipsychotic is recommended, it is very important that treatment is started at low doses and doses are titrated upwards slowly

Typical (1st generation) antipsychotics should not be used in BPSD.

Risperidone is licensed for use in Alzheimer’s disease. The licensed indication is "the short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others". For guidance on dose, see DPT prescribing guideline PG14: Pharmacological Management of Severe Behavioural & Psychological Symptoms of Dementia (BPSD)

Alternative pharmacological options

Where risperidone is contraindicated or where no clinical benefit is achieved and/or the individual experiences intolerable side effects, it may be appropriate to consider alternative pharmacological treatment options (to be initiated by or on the recommendation of a specialist). Refer to the DPT prescribing guideline PG14: Pharmacological Management of Severe Behavioural & Psychological Symptoms of Dementia (BPSD)

Communication with Primary Care

In some circumstances it may be appropriate for the medication to be continued in primary care for an agreed period of time, following review by a specialist. Where this is appropriate the specialist will:

• contact the individual's GP to request that they accept on-going responsibility for prescribing
• provide the GP with a clear treatment plan to cover the reduction and discontinuation of medication for BPSD and who to contact if they need to seek further advice on the clinical management of the individual (i.e. original symptoms re-emerge on discontinuation of treatment)
• include a summary of the information documented in the clinical notes regarding target symptoms and choice of medication and rationale for treatment

Monitoring

• Treatment should be time limited and reviewed regularly
• Regularly monitor response to treatment/changes in target symptoms
• Assess cognition at regular intervals
• Weekly monitoring of sedation, fluid intake and early indicators of chest infection is strongly recommended. Antipsychotics are also associated with increased mortality in the long term (often related to pneumonia and thrombo-embolic events) which can be caused by over-sedation and dehydration.
• Monitor for emergence of side effects associated with medication. Discuss with individual and/or carer and review treatment if side effects intolerable or severe.
• People with dementia with Lewy bodies and Parkinson’s dementia have increased sensitivity to antipsychotic side effects, including acute & severe physical deterioration – monitor carefully

Treatment review

• Treatment should be reviewed at 6 weeks (with earlier review considered according to clinical need).
• Unless there is severe risk or extreme distress, the recommended default management is to discontinue antipsychotic medication. The specialist to provide the GP with a clear treatment plan to cover the reduction and discontinuation of medication for BPSD and who to contact if they need to seek further advice on the clinical management of the individual (i.e. original symptoms re-emerge on discontinuation of treatment)
• Medication should only be continued for people who still have continuing BPSD, where it is felt that severe adverse consequences may occur (or have occurred) if they are discontinued or where no alternative treatment approaches are suitable.
• If treatment is continued, review at least every six weeks. Consider trying to discontinue treatment at each review, where appropriate

Leaflets on dementia for patients/family/carers can be found on the Alzheimer's Society website