Understanding and Managing Behavioral and Psychological Symptoms of Dementia

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CONFERENCE REPORTER

In his well-attended 2023 APA Annual Meeting session, “A Clinician’s Guide to the Management of Behavioral and Psychological Symptoms of Dementia in the Era of Boxed Warnings,” Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP, discussed emerging data on various important aspects of dementias, the most common neurodegenerative conditions in human beings. As Tampi shared, there are over 5 million individuals with dementias in the United States, and this number is projected to rise to over 11 million over the next 30 years. Despite increased prevalence, the diagnosis and management of these disorders is not standardized. How can clinicians address behavioral and psychological symptoms of dementia (BPSD)?

“Recognition is the first and most important step,” said Tampi. “Treatment must always be individualized—it is not one-size-fits-all.”

Common symptoms of BPSD include¹:

-Anxiety (21% to 60%)

-Apathy (48% to 92%)

-Delusions (16% to 70%)

-Depression (30% to 50%)

-Disinhibition/impulsivity (30% to 35%)

-Hallucinations (4% to 76%)

-Inappropriate sexual behaviors (7% to 25%)

-Mood lability (30% to 40%)

-Sleep disturbance (20% to 25%)

-Stereotyped behaviors (12% to 84%)

-Weight loss (15% to 20%)

If you suspect a patient has BPSD, you can follow Tampi’s recommended assessment1 to confirm:

1. Obtain the patient’s history. Medical, psychiatric, medications, premorbid personality, cognition, function, etc.

2. Complete a physical examination so as to rule out underlying medical or neurological disorders.

3. Order investigations, such as blood tests, urine examinations, vitamin B₁₂ and folate levels, neuroimaging, and more.

4. Complete standardized rating scales and/or neuropsychological testing.

5. If there are underlying medical or neurological disorders, treat them.

6. If any medications have adverse effects, remove the offending drug.

7. Confirm the patient has BPSD.

Tampi also provided attendees with evidence-based, nonpharmacological interventions. According to data from systematic reviews, psychoeducation and staff instruction were effective in reducing BPSD symptoms.² Additionally, person-centered care, communication skills training, and adapted dementia care mapping reduced agitation in care homes immediately and for up to 6 months.³ Activities and music therapies also saw some effect in reducing overall agitation.³

As to pharmacological treatments, Tampi shared with attendees that if monotherapy fails, clinicians should use judicious combinations of medications, such as antidepressants with antipsychotics or mood stabilizers. He also stated clinicians should frequently assess efficacy and adverse effects of any and all medications, specifically controlling modifiable cerebrovascular and cardiovascular risk factors.⁴

“It’s how we prescribe that matters,” said Tampi.

References

1. Tampi RR, Bhattacharya G, Marpuri P. Managing behavioral and psychological symptoms of dementia (BPSD) in the era of boxed warnings. Curr Psychiatry Rep. 2022;24(9):431-440.

2. Livingston G, Johnston K, Katona C, et al. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry. 2005;162(11):1996-2021.

3. Livingston G, Kelly L, Lewis-Holmes E, et al. A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia. Health Technol Assess. 2014;18(39):1-226, v-vi.

4. Tampi RR, Williamson D, Muralee S, et al. Behavioral and psychological symptomsof dementia: part ii—treatment. Clinical Geriatrics. June 2011. Accessed May 30, 2023. https://medicine.yale.edu/intmed/geriatrics/fellowships/medicine/bpsd_part%202_clinical%20geriatrics_101891_284_38753_v1.pdf