Exploration of Methods Aimed at Managing BPSD
Background
The human population is aging at an alarming rate and the number of people affected by dementia worldwide is predicted to increase from 44 million in 2013 to 135 million by 2050. Behavioral and psychological symptoms of dementia (BPSD for short) are core features of dementia, and they affect up to 90% of patients. BPSD not only affects the patient but also the caregiver. Caregivers often experience high economic burdens, stress, and financial problems such as decreased income. So, how can we manage BPSD and lessen the burden of both the patients and caregivers?
Objective
This article focuses on a study conducted at Washington State University, which evaluates various methods of management of BPSD and determines the most effective. Studies were conducted on pharmacological and non-pharmacological approaches and were focused on recent findings and discoveries and their effect on patients with BPSD. Based on this study, the article will go in-depth on the three steps needed for managing BPSD, and provide evidence from other studies.
Step One
There are three main steps used when assessing BPSD. The first step is to thoroughly assess the patient’s BPSD. This is done in two steps:
Obtaining an accurate medical and psychiatric history. This includes substance use, the underlying cause of dementia, and the patient’s cognitive and functional baseline.
Next, specify and characterize the BPSD, the context surrounding the behavior of the patient, and assess for other symptoms of dementia. Environmental and psychological factors can also be identified.
In addition, there are three structured models that are useful for the process of assessing BPSD, but only two have had consistent and beneficial results. One is the DICE model It describes the problematic behavior, investigates possible causes of the behavior, creates a treatment plan, and evaluates the outcome of this plan. This is a patient and caregiver-centered approach, and it is applicable in many treatment settings. A recent consensus statement listed DICE as one of the two most promising non-pharmacological approaches for BPSD overall and for agitation. The second model is TIME (Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms). This is a three-phase approach used in moderate to severe agitation in people with dementia. This approach has been studied in a single-blinded, cluster, randomized controlled trial conducted in 33 nursing homes in Norway, which showed significant reduction of agitation at both 8 and 12 weeks in intervention group relative to control group.
Step Two
After a detailed assessment, the next step is to address any medical causes. Some infections, that would not cause behavioral or psychological symptoms in healthier patients, might manifest as BPSD in patients with dementia. When treating BPSD caused by infection, the site of infection should be identified before antibiotic treatment. It often takes days to weeks for BPSD to improve after beginning treatment. One specific antibiotic, fluoroquinolones, has been associated with disturbances in attention, disorientation, agitation, anxiety, amnesia, and delirium and should be avoided in patients with dementia if possible. More than half of antibiotic courses prescribed in long-term care facilities are unnecessary and, when necessary, are often administered for longer than needed.
Moreover, the prevalence of pain amongst patients with dementia is high, with one study citing a range from 47 to 68%. It often goes unrecognized or untreated because dementia patients have difficulty reporting and describing their pain. A recent review by Huesbo et al. in 2016 suggests that the most consistently studied and effective intervention for pain is acetaminophen (a pain killer similar to ibuprofen) up to 3000 mg per day. Oddly, this review also brings to light that community-dwelling people with dementia were more likely to receive strong opioids (e.g., fentanyl) than people without dementia when stronger pain killers were used.
It is important to pay special attention to medications that could contribute to or even cause BPSD, especially medications with anticholinergic properties, sedative-hypnotic drugs, opioids, and alcohol. One recent study showed that reducing anticholinergic burden by at least 20% significantly reduced the severity and frequency of BPSD and decreased caregiver burden. Anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter.
The Final Step
The final step is to experiment with non-pharmacological and pharmacological interventions. Non-pharmacological interventions should always be tried before pharmacological interventions, as patients with dementia often already have significant polypharmacy, which may contribute to BPSD. But there were several shortcomings regarding this area of study. There is insufficient evidence of efficacy, difficulty in implementing strategies, and limited applicability to patients with dementia living on their own (most studies were conducted in long-term care).
Pharmacological interventions only show moderate effectiveness. It must be used with utmost caution. When prescribing and start at low doses, and eventually discontinue. Antipsychotics and antidepressants were the most effective in clinical trials.
Results
Developing a management plan for BPSD relies on the patient’s needs, cause of dementia, and the resources and caregivers available. Therefore, it is highly individualized. Most methods will also help to eliminate medications and substances contributing to BPSD, but more studies are needed given the average age of the population. Also, most of the studies were conducted in long-term care. As stated by Laurel J. Bessey, one of the researchers for this study, “Much of the existing evidence is based on small sample sizes and the heterogeneity of study design. The waxing and waning nature of BPSD, improvement of symptoms with time, and high placebo response rates limit our ability to determine which interventions are effective.” Innovations and upcoming technology will help provide more options to improve treatments for BPSD patients and reduce the burden of caregivers.