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Behavioural and psychological symptoms of dementia (BPSD) occur in about 90% of individuals with dementia, causing considerable distress and potentially interfering with patient care. The presenting neuropsychiatric symptoms include psychosis, agitation, aggression, mood disorder and wandering.
NICE guideline NG97: assessment, management and support for people with dementia and their carers (issued June 2018) includes the management of agitation, aggression, distress and psychosis for people with dementia which is addressed further below. Recommendations for depression, anxiety and sleep disorders are included in the guideline.
For further details, see the Devon Partnership Trust (DPT) Prescribing Guideline PG14- Pharmacological Management of Severe Behavioural & Psychological Symptoms of Dementia (BPSD)
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.
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:
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.
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)
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)
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.
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.
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:
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:
When using antipsychotics:
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)
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)
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:
Leaflets on dementia for patients/family/carers can be found on the Alzheimer's Society website