Copyrighted and permission granted by Ezyhealth Media Pte Ltd Behavioural and psychological symptoms of dementiaby Dr Joshua Kua Hai Kiat
Behavioural and psychological symptoms of dementia (BPSD) have been defined as symptoms of disturbed perception, thought content, mood, or behaviour that frequently occur in patients with dementia. They affect almost all people with dementia at some point during the progression of the disorder.1 The prevalence ranges from 61% to 92%.
The pathogenesis of BPSD has not been clearly delineated but it is probably the result of a complex interplay of biological, psychological, social, and environmental factors.
Various BPSD occur at different phases of illness. Mood symptoms are more likely to occur earlier in the course of the illness. Agitated and psychotic behaviours are frequent in patients with moderately impaired cognitive function. However, these become less evident in the advanced stages of dementia, most likely because of the deteriorating physical and neurological condition of the patient.
Early detection of BPSD is extremely important because untreated BPSD can contribute to more caregiver stress2, premature institutionalisation, poorer quality of life for both the caregiver and the patient, excess disability and increased financial cost. Remission or reduction of BPSD, however, is known to produce remarkable improvement in the functional abilities of the patient, delay nursing home placement and improve patients' and caregivers' quality of life.
Dr Joshua Kua is Consultant Psychiatrist BPSD can be assessed clinically or be rated objectively using standardised at Raffles Counselling instruments which may be either self-rated, caregiver-based or observer Centre. In 2001, he reports. These include the Behaviour Pathology in Alzheimer's Disease received specialist accreditation in (BEHAVE-AD), Neuropsychiatric Inventory (NPI), Cohen-Mansfield Agitation psychiatry and Inventory (CMAI) and the non-cognitive subscale of the Alzheimer's Disease obtained his post- Assessment Scale (ADAS-Noncog).
graduate diploma (with distinction) in psychotherapy at NUS. He was formerly Chief, Department of Geriatric Psychiatry at the Institute of Mental Health. His clinical interests include adult psychiatry (including The prevalence of delusions in people with dementia has been reported to be stress, depression, anxiety and psychosis), between 10% and 73%. The delusions are typically less complex and organised geriatric psychiatry, psycho-oncology, medico- than those observed in non-demented psychotic patients.3 Generally, the legal/forensic issues (especially mental capacity assessment), counselling and psychotherapy. presence of delusions is a significant predictor of physical aggression.
MG Singapore DECEMBER 2012 47
Copyrighted and permission granted by Ezyhealth Media Pte Ltd The types of delusions include: correlation between cognitive impairment and depression, indicating that the • Theft
onset of depression might occur at any stage of the disease. This is probably due to As the dementia progresses, diagnosis of depression becomes more patients not being able to difficult because of the increasing communication difficulties, and because remember the precise location apathy, weight loss, sleep disturbance, and agitation can occur as part of of common household objects and hence form the fertile Depressive disorder should be considered when one or more of the soil for development of the following conditions are noted: compensatory delusional ideas • acute, unexplained behaviour changes • the patient exhibits a pervasive depressed mood and loss of pleasure • Spouse (or other caregiver)
• the family suspects depression is an impostor
• family or personal history of depression prior to the onset of dementia This can also be classified as • rapid decline in cognition misidentification or as Capgras The Cornell Depression Scale in Dementia specifically assesses depression in dementia and has been shown to be a useful screening instrument in our local population.4 Occasionally, persons with dementia will become convinced that their spouse is unfaithful – Apathy and related symptoms are among the most common of the BPSD sexually or otherwise, and can (present in up to 50% in early and intermediate stages of AD and other lead to aggressive behaviour. dementias). Apathy may increase with severity of AD.
Although lack of motivation occurs in apathy and depression, the syndrome of apathy denotes lack of motivation without the dysphoria or The frequency of hallucinations in vegetative symptoms of depression.
people with dementia ranges from 12% to 49%. Visual hallucinations are the most common (occurring A recent Canadian study found the prevalence of anxiety disorders in in up to 30%), and these symptoms Alzheimer's Disease (AD) and other dementias to be 16% versus 4% in age- are more common in moderate matched, non-demented controls.5 Patients with anxiety and dementia may than in mild or severe dementia. express previously non-manifest concerns about their finances, future and Visual hallucinations are particularly health (including their memory), and worries about previously non-stressful common in subjects with dementia events and activities like being away from home or being left alone.
with Lewy bodies (DLB). They are Patients with AD sometimes develop other phobias, such as fear of crowds, recurrent, and typically consist of travel, the dark, or activities such as bathing.
well formed images of animals or persons that the patient describes in Motor Function Symptoms
detail. Patients with dementia may also have auditory hallucinations Wandering behaviours include aimless walking and exit seeking/repeatedly attempting to leave the house. It often results in persons having dementia One common visual being admitted to a long-term care facility.
hallucination involves seeing people Faulty orientation ability, changed environment, memory problem, in the home who are not really there boredom, excess energy, discomfort/pain, and anxiety may underlie some – for example, phantom boarders wandering behaviours. At times, it may just be ‘wondering' behaviour – the – that can also be considered as a cognitively impaired persons trying to make sense of their environment or searching for people or the past.
Physical Resistance to Care
Resistance to care may involve resisting taking medications or ADL assistance. Studies show depressed mood to It is related to the ability of the person with dementia to understand, and occur most frequently in 40% to thus, it increases in prevalence with worsening of cognitive impairment. It is 50% of patients with AD, with a associated with verbally and physically abusive behaviour towards caregivers.
major depressive disorder being less common than sub-syndromal depression. There is generally no Its prevalence in persons having dementia increases with degree of 48 MG Singapore DECEMBER 2012
Copyrighted and permission granted by Ezyhealth Media Pte Ltd cognitive impairment. Agitation in persons having dementia is a complex phenomenon. Neurobiological The assessment of BPSD
changes, medical factors, psychological, social, and requires specific and detailed
environmental factors interacting with premorbid personality, influence the development of agitation.
information about the clinical
history, patient's subjective
Catastrophic reaction is an acute expression of
experiences, and objective
overwhelming anxiety and frustration – often behaviour. Information from a
triggered in persons having dementia by adverse experiences such as frustration with getting reliable caregiver is pertinent.
dressed or with other such experiences. These reactions are also sometimes referred to as rage reactions. They are typically brief and self-limited, and manifest as sudden angry outbursts, verbal aggression (e.g. shouting and cursing), threats of physical aggression, and physical aggression. Sun-downing
Sun-downing is the occurrence and exacerbation of BPSD in the
afternoon or evening. Agitation and sleep disturbances commonly
accompany sun-downing. Sun-downing increases the burden of care on
recommend non-pharmacological caregivers, as it often occurs when the staffing in institutional settings is interventions as first-line treatment at the lowest levels.
followed by the least harmful medication for the shortest time Inappropriate verbal and physical sexual behaviours involve persistent, The assessment of BPSD uninhibited sexual behaviours directed at oneself or at others. These may requires specific and detailed take the form of making inappropriate sexual comments to taking their information about the clinical clothes off at inappropriate time or setting to inappropriately touching or history, patient's subjective molesting others. They are profoundly disruptive to caregivers (family and experiences, and objective professional) and other individuals in the immediate surroundings.
behaviour. Information from a reliable caregiver is pertinent. Circadian Rhythm Symptoms
The doctor should review possible physical causes (delirium, Sleep pattern changes in dementia include hypersomnia, insomnia, sleep- pain, infection, constipation, wake cycle reversal, fragmented sleep, and rapid eye movement sleep etc.) as well as the medication behaviour disorder. Patients with dementia often show daytime napping and list (especially for sedatives and night-time awakenings associated with poor quality of sleep. Several factors drugs with anticholinergic effects). (e.g. pain, need to urinate during the night, medications [diuretics], as well One should look for contributing as stimulants such as coffee and bronchodilators), may contribute to this environmental factors (e.g. noise associated with shift change). After comprehensive assessment and Appetite and Eating Behavioural Symptoms
treatment of underlying medical Appetite changes can be quantitative (anorexia or hyperphagia) causes, specific behavioural or or qualitative (preference for particular foods associated or not to changes psychological symptoms are then in taste). The preference for sweets is particularly frequent in frontotemporal dementia. Most dementia patients lose weight, which can be due to The general principles in hypermetabolism and inflammatory processes, in relation with • to understand the cause of the behaviour disturbance (e.g. environmental factors, stressful The main objectives in the management of BPSD are to ameliorate the tasks or caregiver reactions) BPSD, maximise functional independence, improve the quality of life • decide if the symptoms need to of patients, and minimise caregiver stress and distress. Current guidelines MG Singapore DECEMBER 2012 49
Copyrighted and permission granted by Ezyhealth Media Pte Ltd • formulate a management plan with the caregiver• implement specific strategies• review care plans regularly Non-pharmacological Management
Non-pharmacological interventions are usually first line management for
mild to moderate BPSD, and it has been shown that environmental and
behavioural interventions in conjunction with caregiver education, training
and support are effective.
Medication may be indicated if non-pharmacological interventions have
failed or when the symptoms are moderate or severe and has had an
adverse impact on the person with dementia or his caregiver.
Guidelines to pharmacotherapy: • Treat only moderate or severe BPSD with medication.
• Use lower doses especially in the elderly.
• Target specific behaviours e.g. hallucinations, delusions, aggression
[see Table 1].
• Start with one drug at a time.
• Be aware of adverse effects and drug sensitivity.
• Regular reviews of medication effects and side effects.
• Make sure use of medication is time limited.
Daily Dose range
Side effects /
(0.25mg to 2mg)
• Over sedation
(2.5mg to 10mg)
• Atypical anti-psychotics
possible raised risk
adverse events and
(0.5mg to 2mg)
prolongation of Q-T
• Nausea and GIT
Tariot PN, Mack JL, Patterson MB, Edland SD, Weiner MF, Fil enbaum G, et al. The Behavior Rating Scale for (25mg to 150mg)
Dementia of the Consortium to Establish a Registry for Alzheimer's Disease. The Behavioral Pathology • Escitalopram
Committee of the Consortium to Establish a Registry (5mg to 20mg)
for Alzheimer's Disease. Am J Psychiatry 1995; 152: • Drug interactions
• Paroxetine CR
2 Tan LL, Wong HB, Al en H. The impact of (6.25mg to 25mg)
neuropsychiatric symptoms of dementia on distress in family and professional caregivers in Singapore. Int • Fluoxetine
• Serotonin syndrome
Psychogeriatr. 2005 Jun;17(2):253-63.
(10mg to 30mg)
3 Jeste DV, Meeks TW, Kim DS, Zubenko GS.Review Research agenda for DSM-V: diagnostic • Trazodone
categories and criteria for neuropsychiatric syndromes (25mg to100mg)
in dementia.J Geriatr Psychiatry Neurol. 2006 Sep; • Mirtazapine
Lam CK, Lim PP, Low BL, Ng LL, Chiam PC, Sahadevan S. Depression in dementia: a comparative and validation (15mg to 45mg)
study of four brief scales in the elderly Chinese. Int J Geriatr Psychiatry 2004;19(5):422-8.
5 Nabalamba, A., Patten, S.B. Prevalence of mental (5mg to 10mg)
• GIT symptoms
disorders in a Canadian household population with dementia. Can J Neurol Sci 2010; 37(2): 186–94.
6 Azermai,M., Petrovic,M., Elseviers, M. (6mg to 12mg)
M.,Bourgeois,J.,Van Bor- tel,L.M.,Vander Stichele,R. H. (2011).Systematic appraisal of dementia guidelines • Galantamine
for the management of behavioural an dpsychological (16mg to 24mg)
symptoms. Ageing Res.Rev. 11, 78–86.
Table 1. Pharmacological Interventions
50 MG Singapore DECEMBER 2012
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