Behavioral and psychological symptoms of dementia (BPSD), i.e. verbal and physical aggression, agitation, psychotic symptoms (hallucinations and delusions), sleep disturbances, oppositional behavior, and wandering, are a common and potentially severe problem complicating dementia. Their prevalence is very high and it is estimated that up to 90% of patients with Alzheimer’s disease (AD) may present at least one BPSD. Beside the obvious impact on the quality of life of people with dementia, BPSD are responsible for increased risk of patient institutionalization and increased costs. Furthermore, they are associated with caregivers’ stress and depression. Drugs used include antipsychotics, antidepressants, anticonvulsivants, anxiolytics, cholinesterase inhibitors and N-methyl-D-aspartate receptor modulators. Among these, the most commonly used are anti-psychotics. These drugs have been used for many decades, but in the last years new compounds have been marketed with the promise of comparable efficacy but less frequent adverse effects (especially extra-pyramidal side effects). Their safety, however, has been challenged by data showing a potential increase in adverse cerebrovascular side effects and mortality. This review will summarize the pathophysiology and neuropharmacology of BPSD, it will describe the characteristics of the anti-psychotics most commonly used focusing on their efficacy and safety in BPSD.

/pdf/antipsychotics-for-the-treatment-of-behavioral-and-1hyrsauth3.pdf

Antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD).

SUMMARY Background Behavioural and psychological symptoms of dementia (BPSD) are often reported in institutions for the elderly. Objective To evaluate the effectiveness of a staff education intervention to manage BPSD in older people with a diagnosis of dementia. Methods The trial was conducted in 16 nursing homes; 306 patients with a diagnosis of dementia and presenting BPSD were selected. Nursing homes were randomly allocated to an intervention group or a control group. An 8-week staff education and training programme was conducted in the nursing homes in the intervention group. The main outcome measures were the Cohen-Mansfield Agitation Inventory (CMAI) and an Observation Scale (OS) score. Assessments were done at baseline (W0), at the end of the ‘intervention’ period (W8) and 12 weeks after (W20). Results Therewas a significant decrease in the global CMAI score between baseline and W8 (� 7.8; p >0.01) and between baseline and W20 (� 6.5; p >0.01) in the intervention group but not in the control group. Results of mixed linear models showed that the CMAI global score, the CMAI physically non-aggressive behaviours subscale score and verbally nonaggressive behaviours subscale score significantly decreased in the intervention group ( p <0.001) although there was no significant evolution in the control group. Direct assessment with the OS produced the same pattern of results, with a significant decrease only in the intervention group. Conclusion The intervention reduced BPSD in severely demented nursing home residents and this effect was still present 3 months after the end of the programme. Copyright # 2009 John Wiley & Sons, Ltd. key words—Alzheimer’s disease; BPSD; staff training; disruptive behaviours

Non-pharmacological management of behavioural symptoms in nursing homes.

The etiology of behavioral and psychiatric symptoms is generally considered to be multifactorial, and these symptoms often indicate a need for care or assistance, which may include the presence of uncontrolled pain. The aim of this cross-sectional study was to assess the association of pain with behavioral and psychiatric symptoms in a population of nursing home (NH) residents with cognitive impairment in Europe. Data are from the SHELTER project, which contains information on NH residents in 8 countries. Pain was defined as any type of physical pain or discomfort in any part of the body in the 3 days before the assessment. The mean age of 2822 cognitively impaired residents entering the study was 84.1 (standard deviation 9.1) years, and 2110 (74.8%) were women. Of the total sample, 538 residents (19.1%) presented with pain. After adjusting for potential confounders, pain was significantly and positively associated with socially inappropriate behavior (odds ratio [OR] 1.37; 95% confidence interval [CI] 1.04–1.80), resistance to care (OR 1.41; 95% CI 1.08–1.83), abnormal thought process (OR 1.48; 95% CI 1.16–1.90), and delusions (OR 1.48; 95% CI 1.07–2.03). A borderline inverse association was observed with wandering (OR 0.74; 95% CI 0.55–1.00). In conclusion, this cross-sectional study provides evidence from a large sample of frail elderly showing an association between pain and behavioral and psychiatric symptoms. Treatment models that put together assessment and treatment of pain and evaluate their effect on behavioral and psychiatric symptoms are needed.

Association of pain with behavioral and psychiatric symptoms among nursing home residents with cognitive impairment: Results from the SHELTER study

Background: The management of disruptive neuropsychiatric symptom (NPS) such as agitation and aggression (A/A) is a major priority in caring for people with Alzheimer's disease (AD). Few effective pharmacological or non-pharmacological options are available. Results of randomized clinical trials (RCTs) of drugs for A/A have been disappointing. This may result from the absence of biological efficacy for medications tested in treating A/A. It may also be related to methodological issues such as the choice of outcomes. The aim of this review was to highlight key methodological issues pertaining to RCTs of current and emerging medications for the treatment of A/A in AD. Methods: We searched PubMed/Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for RCTs comparing medications with either placebo or other drugs in the treatment of A/A in AD, between January 2008 and December 2013. Results: We identified a total of 18 RCTs; of these, 11 were completed and 7 ongoing. Of the ongoing RCTs, only one is in Phase III. Seven of 10 completed RCTs with reported results did not report greater benefit from drug than placebo. Each of the completed RCTs used a different definition of "clinically significant A/A." There was considerable heterogeneity in study design. The primary endpoints were largely proxy-based but a variety of scales were used. The definition of caregiver and scales used to assess caregiver outcomes were similarly heterogeneous. Placebo response was notable in all trials. Conclusions: This review highlights a great heterogeneity in RCTs design of drugs for A/A in AD and some key methodological issues such as definition of A/A, choice of outcome measures and caregiver participation that could be addressed by an expert consensus to optimize future trials design.

/pdf/medication-development-for-agitation-and-aggression-in-1yvrw0ngvl.pdf

Medication development for agitation and aggression in Alzheimer disease: review and discussion of recent randomized clinical trial design

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) have been associated with increased carer burden and early institutionalization. BPSD are more responsive to treatment than are cognitive and functional decline. Little is known about how family carers understand and try to reduce these symptoms. This study aimed to explore the strategies used by carers looking after someone with high levels of BPSD. METHODS: Twenty-five carers were interviewed using a semi-structured interview with the Neuropsychiatric Inventory (NPI). They were all caring for someone eligible for an Extended Aged Care at Home Dementia Package, which targets people with BPSD. RESULTS: Participants reported high levels of BPSD with a mean score of 8.2 for symptoms (range 2-12, SD = 2.38) and a mean NPI score of 51.4 (range 14-111, SD = 28.74). Distress scores were also high with a mean of 18.5 (range 2-42, SD = 11.33). Carers described on average, fewer than four strategies for managing BPSD. Encouraging activity, utilizing psychotropic medications, identifying triggers, restraining or treating in a paternalistic manner, and meeting physiological needs were the most commonly used strategies. CONCLUSION: While family carers are often at the forefront of identifying triggers and addressing unmet needs, findings from this study suggest that some carers have a limited repertoire of strategies despite experiencing a large number of symptoms. There is a clear need for ensuring evidence-based programs to educate and support carers in identifying triggers, understanding symptoms and learning to cope with these symptoms.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/B6100EAA703EE342F5EABD16FA31958A/S1041610213000070a.pdf/div-class-title-how-do-family-carers-respond-to-behavioral-and-psychological-symptoms-of-dementia-div.pdf

How do family carers respond to behavioral and psychological symptoms of dementia

Professional consensus on the treatment of agitation, aggressive behaviour, oppositional behaviour and psychotic disturbances in dementia.

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Professional consensus on the treatment of agitation, aggressive behaviour, oppositional behaviour and psychotic disturbances in dementia.