Management of behavioural and psychological symptoms of dementia (BPSD)

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.

Assessment and non-pharmacological management

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:

  • an underlying physical cause (including pain)
  • side-effects of medication
  • an underlying depressive illness and/or anxiety disorder

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.

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

Communication of information to family 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).

Individual pharmacological management

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:

  • 91-200 people with behavioural disturbance showing clinically significant improvement in symptoms
  • 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
  • 18 CVAEs of which ~ 50% would be severe (Evidence from observational studies suggests increased risk of CVAE may be confined to the 2-3 month period typically encompassed in RCT follow-up studies, therefore extrapolation of data in the original CSM alert, 2004, proposing that NNH of 37 would translate to NNH of 6.3 over 1 year, resulting in an additional 159 CVAEs per 1000 people treated, may be an over-estimation)
  • No additional falls or fractures
  • 58-94 people with gait disturbance

Initiation of pharmacological treatment

Risperidone

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.

Treatment review and discontinuation

Treatment review

  • Treatment should be time-limited and reviewed regularly
  • Regularly monitor response to treatment/changes in target symptoms
  • Assess cognition at regular intervals
  • Monitor for emergence of side effects associated with mediation. Discuss with individual and/or carer and review treatment if side effects intolerable or severe.
  • Note: people with Dementia with Lewy bodies have increased sensitivity to antipsychotic side effects, including acute & severe physical deterioration. In this population it is very important that treatment is started at low doses and doses are titrated upwards slowly.
  • Ensure on-going physical monitoring is carried out appropriate to the medication prescribed
  • Treatment should be reviewed at 6 and/or 12 weeks (with more frequent review considered according to clinical need). Unless there is severe risk or extreme distress, the recommended default management is to discontinue antipsychotic medication

Discontinuation of treatment

  • Daily dose of risperidone less than or equal to 500 micrograms, immediate discontinuation is recommended
  • Higher doses require a gradual reduction, i.e. reduce dose by 50% of total daily dose every 1-2 weeks until dose of 500 micrograms or less/day reached, then stop minimum dose after 1-2 weeks

 

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