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Managing Behavioral and Psychological Symptoms of Dementia in the Era of Black Box Warnings

Managing Behavioral and Psychological Symptoms of Dementia in the Era of Black Box Warnings

Neurology of behavioral and psychological symptoms of dementiaTABLE 1: Neurology of behavioral and psychological symptoms of dementia
Algorithm for assessing behavioral and psychological symptoms of dementiaFigure 1. Algorithm for assessing behavioral and psychological symptom...
Algorithm for the management of behavioral and psychological symptoms Figure 2. Algorithm for the management of behavioral and psychological...
Pharmacotherapeutic agents for behavioral and psychological symptoms of dementiaTABLE 2: Pharmacotherapeutic agents for behavioral and psychological s...

Behavioral and psychological symptoms of dementia (BPSD) are a heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors that are unsafe and disruptive and impair the care of the individual. About one-third of community-dwelling individuals with dementia exhibit BPSD.1 The prevalence increases to approximately 80% in individuals residing in nursing facilities.2

Jost and Grossberg3 found that behavioral symptoms were observed in 72% of individuals more than 2 years before the actual diagnosis of dementia. The prevalence of BPSD increased to 81% 10 months after the formal diagnosis of dementia. Unlike cognition, which declines over time in individuals with dementia, BPSD tends to fluctuate; agitation is the most persistent symptom.4

Apathy is the most common problem in individuals with dementia; it tends to occur early in the course of illness and remains stable through the course of the illness. Delusions commonly seen in individuals with dementia include false beliefs (eg, of theft, infidelity, misidentification syndromes). Individuals with dementia who have a family history of depression appear to be at greater risk for a major depressive episode than those without a family history. Disinhibition occurs in approximately one-third of the patients. In patients with hallucination, the most common form is visual hallucination. Irritability and mood lability become more prevalent with the progression of dementia.

Findings indicate that BPSD occurs because of the complex interactions between anatomical, functional, and biochemical changes that occur in the brain. Certain genes can predispose individuals to BPSD, and premorbid personality may contribute to the emergence of certain types of behavioral symptoms. Table 1 details the various neurobiological changes that contribute to the development of BPSD.

BPSD is associated with greater overall burden of care for individuals with dementia.5 The emergence of BPSD often results in the referral of patients with dementia to a specialist’s care. Paranoia, aggression, and sleep-wake cycle disturbances are associated with greater caregiver burden, caregiver depression, and the risk of institutionalization. BPSD results in the worsening of activities of daily living, faster cognitive decline, and a poorer quality of life. It also adds to the overall direct and indirect cost of care for individuals with dementia after adjusting for the severity of cognitive impairment and other comorbidities.6,7

Assessment

Assessment includes collateral information from caregivers and/or family members. Collateral information aids in determining the onset, the course, and the differential diagnosis of BPSD. It also helps identify risk and prognostic factors. Environmental factors and psychosocial stressors may be triggers for the onset or the worsening of symptoms. Underlying medical conditions, including pain syndromes, urinary tract infection, and dehydration, can result in exacerbation of symptoms. An evaluation for and management of these disorders will reduce the frequency and severity of BPSD and may mitigate the use of psychotropic medications.

Assessment tools such as the Neuropsychiatric Inventory, the Behavioral Pathology in Alzheimer Disease rating scale, the Consortium to Establish a Registry for Alzheimer Disease Behavior Rating Scale for Dementia, Dementia Behavior Disturbance scale, and the Neurobehavioral Rating Scale can be used to aid diagnosis of BPSD.8 These instruments help identify behaviors and rate their severity. They can also assist in tracking progression and in monitoring treatment response. An algorithm for the assessment of BPSD is presented in Figure 1.

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