What is Behavioral and Psychological Symptoms in Dementia ?
Dementia is commonly used to describe what doctors and scientists refer to as Major Neurocognitive Disorder (MND), as described in the Diagnostic and Statistical Manual 5th edition (DSM-5). In simple terms, dementia is identified by a person’s mental decline and loss of ability to carry out daily activities. There are many causes of dementia, including Alzheimer’s, vascular dementia, frontotemporal dementia, Lewy body dementia, and Parkinson’s disease, among other conditions.
There are also behavioral and psychological symptoms tied to dementia, known as BPSD. These include mental symptoms that appear alongside dementia such as hallucinations, delusions, loss of interest in life, anxiety, depression, and loss of inhibition. These BPSD symptoms are common and can have a big impact on the outlook and treatment of dementia patients. BPSD includes emotional, perceptual, and behavioral issues that are similar to symptoms seen in mental health disorders. They’re usually grouped into five categories: cognitive or perceptual (like delusions and hallucinations), motor (like pacing, wandering, and physical aggression), verbal (like yelling and repeated speech), emotional (like extreme happiness, depression, apathy, anxiety, irritability), and vegetative (like sleep and appetite problems).
What Causes Behavioral and Psychological Symptoms in Dementia ?
The exact cause of Behavioral and Psychological Symptoms of Dementia (BPSD) isn’t known. However, it’s believed to be tied to how a person’s biology, past experiences, and current environment interact. BPSD symptoms, such as agitation, lack of restraint, and hallucinations, are linked with changes in certain parts of the brain responsible for managing our emotions, self-awareness, and perception. These changes may include reductions in the volume of certain brain regions, or a decrease in their metabolic activity.
Additionally, BPSD is associated with imbalances in different neurotransmitters (the body’s chemical messengers), such as cholinergic, noradrenergic, dopaminergic, serotonergic, and glutamatergic ones. While this evidence is still early, it primarily relates to Alzheimer’s disease and supports some current treatment methods.
Non-biological factors also play a role in BPSD. For example, personality traits like neuroticism, where a person tends to react strongly to stresses, could also contribute to BPSD. Past experiences of traumatic stress, caregiver communication issues, and environmental factors like over or under stimulation, or surroundings that are too hot, cold, or noisy, can be contributing factors as well.
Three main environmental contributions have been suggested. These include unmet needs like food, fluids, or companionship, behavior, or learning, where unwanted behavior is accidentally reinforced, and a mismatch between a patient’s ability and a caregiver’s expectations.
Risk Factors and Frequency for Behavioral and Psychological Symptoms in Dementia
In 2016, there were about 43.8 million cases of dementia all over the world. This was a 117% increase from 1990. Dementia was also the fifth leading cause of death worldwide and caused 28.8 million disability-adjusted life years (DALYs).
Up to 97% of dementia patients who live in communities will experience BPSD, or behavioral and psychological symptoms of dementia, at some point. The most common symptoms are depression and apathy, but delusions, agitation, and abnormal motor behaviors like fidgeting, repeating behaviors, and wandering, happen in about a third of patients. As time goes on, these symptoms become more severe and often lead to the patient needing institutional care.
Although there’s not a lot of research on how BPSD symptoms relate to the type of dementia a person has, delusions are commonly seen in Alzheimer’s disease, depression and apathy in vascular dementia, and disinhibition and eating disturbances in frontotemporal dementia.
Signs and Symptoms of Behavioral and Psychological Symptoms in Dementia
When dealing with patients who exhibit Behavioral and Psychological Symptoms of Dementia (BPSD), healthcare professionals need to gather detailed histories. This process aims to prioritize the severity and urgency of the symptoms, identify key characteristics, and pinpoint any factors that might be making things worse. This can involve looking at things like the patient’s environment, medication regime, existent discomfort or pain, substance use, and any past or present mental health disorders.
During a physical exam, doctors try to validate the details gathered during the history intake and identify any other psychiatric or medical conditions that might be contributing to the issue.
Behavioral disturbances, often referred to as ‘sundowning,’ are common during the evening hours. This phenomenon affects many dementia patients. Some may also develop misconceptions with paranoid themes. While hallucinations can occur, they are not as common. Some other symptoms that can lead to hospitalization include agitation, aggression, wandering, lack of interest, impulsive behavior, sleep disturbances, and depression.
During a physical exam, these symptoms may not always be noticeable as they tend to come and go. The main aim of the exam is to identify factors that may be contributing to a worsening state of BPSD. Here, the doctor could identify signs of delirium or discomfort. They might also note changes in the patient’s consciousness levels, signs of pain, and any physical signs of acute medical condition like fever, lack of oxygen, abdominal tenderness, fluid overload, inflammation or localized neurological deficits which could indicate delirium.
Testing for Behavioral and Psychological Symptoms in Dementia
If a dementia patient shows slowly worsening behavior and psychological symptoms, it may not be necessary to run lab tests or imaging unless their symptoms suggest other health issues. However, if symptoms develop suddenly, it’s important to run tests to check for things like overall health, liver and kidney function, thyroid performance, and potentially harmful substances. A head CT scan might also be performed.
In facilities like nursing homes, there’s a common belief that urinary tract infections can cause these symptoms. However, half of the residents in these facilities have bacteria that could be mistaken for a urinary tract infection. Therefore, it’s recommended to only run tests and start antibiotic treatment if the patient shows signs of an actual urinary tract infection such as fever, pain, or changes in urination habits.
Setting priorities is crucial. Safety should always be the first concern. If a patient is hurting others, damaging property, or neglecting their basic needs, more intensive management is required, possibly including hospitalization. It’s also important to listen to caregivers’ observations, as this can provide valuable information about the onset, duration, frequency, and conditions of the symptoms.
Lastly, keeping track of medication changes can be crucial because dementia patients may be sensitive to medicines that affect the brain. On top of this, comfort should be evaluated as physical discomfort or pain can increase problematic behavior in dementia patients. Checking for a history of mental health disorders and substance use is also necessary. It’s fundamental to establish a clear baseline to monitor treatment effects efficiently. This baseline can be created using standard tools like the Neuropsychiatric Inventory or the Behavioral Pathology in Alzheimer Disease Rating Scale, based on structured interviews with caregivers.
Treatment Options for Behavioral and Psychological Symptoms in Dementia
In managing behavioral and psychological symptoms of dementia (BPSD), the first step is to create a safe environment for the patient. Hospital settings are often best, especially for patients who might hurt themselves or others. Imaging, lab tests, and sometimes medication is required to determine the best treatment. If the patient is in danger, one-on-one monitoring and antipsychotic medication might be necessary.
Before addressing the BPSD, it’s crucial to deal with any other sources of discomfort for the patient, such as pain, constipation, or urinary issues, and tackle them accordingly.
Next, non-medical strategies are often effective for milder BPSD cases. These might include calming environments, music therapy, or distraction techniques. Some studies suggest caregiver training, which helps those looking after dementia patients better understand and manage BPSD, has a significant impact, reducing symptoms and improving caregiver wellbeing. Certain approaches—like simple tasks, music therapy, and reminiscence therapy—can sometimes help reduce agitation.
If non-medical interventions aren’t enough, medication may be used. These vary depending on symptoms, which can range from delirium and aggression to depression. Pain, for instance, is present in nearly half of dementia patients but often goes unrecognized. If suspected, pain relief treatments could be a first step, as untreated pain is strongly linked with BPSD.
Antipsychotics are often used to treat agitation and aggression, but they come with a high risk of side effects and modest benefits. These are typically a last resort if all else fails. Other medications, like selective serotonin reuptake inhibitors (SSRIs), can also be used to treat depression and apathy.
Overall, the approach to BPSD treatment should be systematic. Before beginning any treatment, establish a baseline for the frequency and severity of the patient’s symptoms, and reevaluate as necessary. For those not responding to standard treatments, researchers are exploring other options, like neurostimulation therapies. However, availability might limit the use of these treatments.
Remember, dealing with BPSD is a gradual process, and results often aren’t instant. The patient’s comfort should always be a top priority, and their behavior should be regularly assessed to make the best decisions for their care.
What else can Behavioral and Psychological Symptoms in Dementia be?
When a doctor is trying to diagnose Behavioral and Psychological Symptoms of Dementia (BPSD), they often consider it could be other mental health conditions such as:
- Delirium
- Schizophrenia
- Bipolar disorder
- Major depression
- Post-traumatic stress disorder
- Brain tumor (CNS neoplasm)
Delirium is similar to BPSD but it usually starts suddenly, may change in severity and is often caused by a medical condition, drug use or withdrawal. Patients with BPSD might also experience delirium, which can make their usual symptoms worse. The key difference is how the symptoms begin. Delirium symptoms usually appear within days or a week or two, while BPSD symptoms slowly get worse over several weeks or months.
Patients with delirium often have issues paying attention and changes in their behavior or awareness of their surroundings. They may have periods of drowsiness or be awake for a long time, which is less common in BPSD. They may also see things that aren’t there, while people with BPSD usually have delusions or false beliefs. Lewy body dementia is often confused with delirium due to similar symptoms, but Lewy body’s symptoms start more slowly. If a doctor suspects delirium, they will do a thorough medical check-up, running tests like blood tests, chest X-rays, and toxicology screens. If the cause is treated, delirium symptoms should start to disappear.
Other psychiatric disorders like schizophrenia, bipolar disorder, major depression and PTSD may look similar to BPSD at first. However, patients usually have a history of these before developing dementia. They usually have episodes of symptoms rather than constant symptoms.
Some brain tumors also cause behavior changes and psychological problems, more so than BPSD. Alongside mood changes and behavioral disturbances, these patients might have other neurological symptoms. A detailed neurological examination is needed, and possibly brain imaging tests, especially for patients with a type of dementia that affects behavior, known as frontotemporal dementia.
What to expect with Behavioral and Psychological Symptoms in Dementia
Dementia is known to significantly reduce life expectancy compared to individuals of the same age without dementia. For instance, men diagnosed with Lewy body dementia or Parkinsonian dementia typically live for about 4.5 years after diagnosis. On the other hand, women diagnosed with Alzheimer’s disease can expect a median survival of 12 years post-diagnosis.
Behavioral and Psychological Symptoms of Dementia (BPSD) are associated with a faster progression of dementia and earlier death. Currently, we don’t know if treatments can alter these outcomes.
Possible Complications When Diagnosed with Behavioral and Psychological Symptoms in Dementia
Behavioral and psychological symptoms of dementia (BPSD) considerably add to the overall impact of dementia on patients, their caregivers, and society. These symptoms can predict faster memory loss and earlier death. They are linked with a longer hospital stay, more hospital complications, earlier admission to nursing homes, and increased rates of mental and heart-related disorders in family caregivers.
No specific studies have mentioned patient and caregiver injuries due to BPSD. However, it’s reasonable to assume that symptoms like agitation and aggression could increase this risk. Whether treatment can influence these factors is not clear. However, interventions that provide training and backup for family caregivers can help to decrease or postpone the need for patients with dementia to stay in a nursing home.
Preventing Behavioral and Psychological Symptoms in Dementia
While no specific studies focus on preventing BPSD, certain strategies have demonstrated a reduction in the risk of mental decline and the onset of dementia. One such strategy involves a combined diet plan of the Mediterranean diet and the Dietary Approach to Systolic Hypertension (DASH). The combination of these diets, along with medical treatment for high blood pressure, can help lower the chances of developing dementia. Physical exercise has also shown to enhance brain function in patients who already have dementia. Depression is linked with an increased probability of developing dementia, however, there is no solid evidence to suggest that treating depression lowers this risk. Similarly, there’s currently no evidence to validate using brain training exercises as a preventative measure.
