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A Must-Read Discussion on the Behavioural and Psychological Symptoms of Dementia

If left untreated, behavioural and psychological dementia symptoms can be extremely distressing for both the person with dementia and their caregivers. In turn, general practitioners can assist in identifying and managing these problems with suitable psychosocial treatments and medications, if necessary, by collaborating in a person-centered manner with caregivers and local community organizations.

Dementia with BPSD

The clinical state of progressive and permanent cognitive impairment that finally becomes sufficiently severe to cause problems with daily functioning is the hallmark of dementia. Essentially, a  multidisciplinary approach is necessary for dementia and Alzheimer's disease management because it is generally complex. Also, a broad category of non-cognitive symptoms like agitation, aggressive behaviour, psychosis, major depressive disorder, and apathy are included under the term Behavioral and Psychological Symptoms of dementia (BPSD), which serves to refer to a variety of non-cognitive symptoms that, unless left untreated, can lead to substantial distress and disability.

While other behavioural symptoms including agitation and violence more frequently eventually appear, notably as the person's capacity to communicate and affect their surroundings declines, depression and anxiety could be considered to be early indications of dementia with BPSD. Such behaviours frequently lead to an increased risk of admission of dementia and Alzheimer disease patients into residential care since they can be exceedingly upsetting for the patient, their family, and caregivers.

Given the prevalence of dementia, we must identify these target symptoms and offer the proper therapeutic strategies to enhance both the lives of people with dementia and their caregivers.

Prevalence, Impact & Symptoms

Up to 80% of patients in one investigation who had dementia displayed at least one neuropsychiatric symptoms from the beginning, and even the patterns of such symptoms can change over time and depending on the degree of dementia. In addition to the mental distress and disabilities that BPSD patients go through, these conditions are linked to higher caregiver stress, more hospitalizations, significant increases in expenses, and early institutionalization.

BPSD generally presents at any phase of dementia, regardless of whether it's still regarded as a mild cognitive impairment. While there are conflicting findings in the studies, several symptoms are more frequently observed in specific types of dementia, such as Lewy body dementia, frontotemporal dementia, and Parkinson's disease, which may induce extrapyramidal symptoms like urinary tract infections.

Meanwhile, the following is a list of the various behavioural and psychological signs of dementia:

  • Anxiety - Can be seen in the forms of asking inquiries about an upcoming event regularly, apprehension of solitude, and worry about one's future, finances, and health.

  • Depressive mood disorders - Increase of statements that are insulting to oneself, loss of enjoyment or a pervasive depressed mood, expressing a desire to pass away. Also includes other depressive symptoms.

  • Hallucinations - Observing people who aren't there in the room, hearing their names called out by people who have passed away.

  • Misidentifications - Misidentification of oneself, other people, and events.

  • Delusions - They believe that there is theft going on, they do not call the house their home, their spouse is unfaithful, their caregiver is an impostor (caregiver distress), and they feel they have been abandoned or they have unmet needs.

  • Apathy - You can observe their absence of interest in routine activities, social interaction has decreased, a decline in emotional receptivity, and they are less initiative.

  • Pessimism - Refusal to collaborate in treating pain, and in consuming food, which leads to worsening the patient's symptoms and cognitive impairment.

  • Disinhibition/Impulsiveness - Observable in impulsivity and inappropriate sexual behaviour.

  • Sleep disturbances - Actively spending the day sleeping and the night awake. May also walk around at night.

  • Wandering - Walking without purpose, and attempting to leave the house on numerous occasions.

  • Agitation - Aggressive symptoms include yelling, cursing, and other violent verbal outbursts. May also include physical symptoms such as grabbing, hitting, pinching, kicking, biting, and slapping.

    It includes behavioural symptoms such as restlessness, pacing, rummaging, repetition in behaviour, bossiness, complaining or whining, continual cries for attention, and other BPSD symptoms.

Factors Causing BPSD

Medical

  • Depression.

  • Anxiety.

  • Delirium; contributing factors are infections, metabolic problems, drug toxicity, or withdrawal from a substance.

  • Pain that goes untreated.

  • Pneumonia or a urinary tract infection in particular.

  • Either hyponatraemia or dehydration.

  • Urinary retention or diarrhoea.

  • Fatigue.

  • Visual or auditory impairment.

Pharmacological

  • Drugs that have an anticholinergic effect, e.g. Oxybutynin and amitriptyline.

  • Anticonvulsants, like Phenytoin and carbamazepine.

  • Systemic corticosteroids, especially in high doses.

  • Medications that have a sedative effect, e.g. Opioids, benzodiazepines, and zopiclone are centrally acting antihistamines.

  • Antipsychotic medications

  • Drugs that treat Parkinson's disease.

Environmental or Social

  • Unfamiliar surroundings.

  • A break with family.

  • Noise.

  • Crowding.

  • Inadequate privacy.

  • Finding services difficult, e.g. Toilet.

  • Access to the outside is challenging.

  • Insufficient room for movement.

  • A sense of insecurity, e.g. unlocked housing arrangements.

  • Sunlight glare, artificial lighting, or inadequate lighting.

  • Under or over-stimulation.

  • The withdrawal process from alcohol or another drug.

  • Loneliness.

  • Relationship with the family caregivers, a relative, or another resident in care that is difficult. (Caregiver stress)

Pharmacological Strategies for BPSD

To manage behavioural and psychological symptoms of dementia, a variety of medications can be utilised.

  • Medications that have anticholinergic effects, such as amitriptyline and oxybutynin

  • Anticonvulsants like carbamazepine and phenytoin

  • Systemic corticosteroids (primarily at high doses)

  • Sedatives like opioids, benzodiazepines, zopiclone, and centrally acting antihistamines

  • Anti-Parkinsonian medications

Of note, there is weak evidence for benzodiazepine use in this condition. Moreover, there are side effects to watch out for, such as sleepiness, lightheadedness, worsening cognition, falls, difficulty breathing, addiction and unexpected behaviours.

Psychosocial or Behavioural Strategies for BPSD

In general, behavioural or psychosocial treatments, along with a number of non-pharmacological interventions, serve as the cornerstone of treatment for BPSD. They ought to always come before pharmaceutical solutions or antipsychotic medications based on MOH Clinical Practice Guidelines.

Resolve Social, Emotional, and Physical Triggers

Many behavioural or psychiatric disorders are a result of unfulfilled social and environmental demands, including social isolation, the desire for contact or intimacy, the need for seclusion when performing personal care, ambient noise, and temperature. Inability to articulate needs due to physical or language limitations, physical or mental distress, immobility, sensory problems, and skin conditions are other frequent triggers that should be frequently assessed for and treated.

Once we are aware of the situations that set off certain behaviours as well as what contributes to their improvement or even worse, we can take a variety of actions to intervene, such as communicating with the person, diverting their attention, or adjusting the surroundings.

Communication

Use basic, direct statements while speaking slowly and employing the right use of your body language, tone, and eye contact. Also, when necessary, give them a choice, refrain from talking down to them, and let them vent their feelings. The most important thing is to keep your calm; shouting or arguing usually makes things worse.

Distraction

Talking about fond memories and diffusing the situation by diverting their attention to another task or relocating to a different location are two strategies for doing this.

Environment

Minimize the amount of clutter, eliminate potentially harmful items from the house, or limit access to them. Add grab bars, and non-slip mats, and remove reflective surfaces, too. Avoid moving, but if it's unavoidable, bring familiar items with you. Apply for a Safe Return Card from the Alzheimer's Disease Association (ADA) for additional alternatives.

Engage in Psychosocial Interventions

Several more psychological treatments are accessible, including music therapy, memory therapy, aromatherapy, animal therapy, as well as multisensory stimulation. Productive activities give patients a feeling of normality by being relevant, utilizing their prior interests and skills, and utilizing their past experiences. Encouragement is also crucial in getting caregivers to concentrate on the procedure rather than the outcome.

Benefit from Elder Sitters and Dementia Daycare Centers

To involve patients with dementia in meaningful activities, a recommendation to a dementia daycare facility through AIC can also be taken into account. While some patients may be hesitant to attend at first, once a regimen has been developed, most patients find the activities to be very enjoyable and frequently anticipate daycare. Eldersitters, on the other hand, is an option if dementia daycare is not a practical solution for some households.

Inform and Empower Caregivers

Provide Sufficient Education to the Caregivers

Caregivers need to be informed about the different levels of dementia, and how behaviours are brought on by the illness rather than being deliberate. Also, they are required to bear the costs of changing ways of communicating, routines, and environments. Moreover, we could perhaps inspire caregivers to look beyond the disease, acknowledge dementia patients as unique people, recall the individual they were before the disease, and lay out their day-to-day care and schedule by the sources of the fulfilment of each patient.

Practice Self-Care

Patients with dementia require a lot of time from their caregivers, which exposes them to the dangers of caregiver burnout and emotional stress. It is indeed essential that we continue encouraging caregivers to engage in self and make time available for their pursuits, doctor appointments, and leisure.

Employ the Help Support Groups

The ADA and Caregivers Alliance, primarily, offers support groups, caregiver education, and pointers on dementia care management. While community initiatives with distinctive care principles include Family of Wisdom and Club Memorable. In cases where caregivers require assistance unexpectedly, home for the aged Singapore services can be provided by a number of companies, including Red Crowns. You can also visit this article to read the benefits of bringing your loved one to a dementia day care centre.

Indeed, there isn't a single treatment plan that works for all dementia patients because they are all distinctive. To preserve autonomy and a high standard of living for persons with dementia, nonetheless, following the suggested course of action and collaborating with caregivers and social organizations to adopt a person-centered strategy can go an extremely fair distance.

Likewise, caregivers are urged to consider the patient as a whole, not only as a person who has an illness or is old, in the interests of treating patients with deeper respect and honour as unique individuals who are part of a deeper connection.

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