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For further details see Mental Health Prescribing Forum Prescribing Guideline PG14- Pharmacological Management of Severe Behavioural & Psychological Symptoms of Dementia (BPSD)
Behavioural and psychological symptoms of dementia (BPSD) occur in about 90% of individuals with dementia, causing considerable distress and potentially interfering with the patient care. The presenting neuropsychiatric symptoms include psychosis, agitation, aggression, mood disorder and wandering.
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.
Pharmacological treatment is not a substitute for other approaches and these techniques must always be used concurrently.
Non-pharmacological approaches must always be considered first.
For individuals with behaviours that challenge, identify and document target symptoms.
Assess whether symptoms could be a result of:
Once these have been discounted consider appropriate non-pharmacological interventions, for example environmental changes, psychological therapies, multisensory stimulation, massage and aromatherapy.
If symptoms do not resolve consider pharmacotherapy.
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 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.
Wandering behaviour does not respond to medication.
The 2009 Banerjee report summarised the risks and benefits of treating 1,000 patients with BPSD with an atypical antipsychotic for around 12 weeks:
Risperidone is the only medication with UK Marketing authorisation for this indication, licensed for "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".
Initial dose of 250 micrograms twice a day recommended Increase if required, according to response in steps of 250 micrograms twice a day on alternate days. Usual dose 500 micrograms twice a day (but doses up to 1mg twice a day may be beneficial for some individuals). Exercise caution if risperidone is prescribed together with furosemide (higher incident of mortality observed although mechanism unclear). The risks and benefits of combining risperidone with furosemide or other potent diuretics must be considered prior to use. Refer to Risperidone SPC for more information.The most important adverse effects associated with antipsychotics are parkinsonism, falls, dehydration, chest infections, ankle oedema, deep vein thrombosis/pulmonary embolism, cardiac arrhythmia and stroke (highest risk in first four weeks of treatment). 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.
Complete a cardiac risk assessment prior to initiating treatment.
Weekly monitoring of sedation, fluid intake and early indicators of chest infection is strongly recommended.
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 DPT PG14 for further guidance.