Dementia’s behavioral and psychological symptoms are poorly known, and its treatment is also little understood. It’s difficult to say what acts constitute a behavioral manifestation.
Disturbing behaviors (agitation, wandering, eating issues) and psychiatric symptoms (delusions, hallucinations, and emotional abnormalities) are among the symptoms and indicators of dementia.
These are often referred to as Behavioral and Psychological Symptoms of Dementia (BPSD), a term coined by the International Psychogeriatric Association in the 1990s to help with clinical trials in this field. However, it has never gained traction in primary care.
According to some research, the occurrence of dementia rises from 7% in those around 60 to 64 years to over 40% in those who are 90 years or older.
Tolerance (how much caregivers could accept) is partly influenced by the person’s housing conditions, particularly their safety. Wandering, for example, maybe tolerated if a person lives in a safe facility. However, wandering may be troublesome if where the person living with dementia resides does not have appropriate safety measures in place.
Etiology
Cognitive alterations associated with dementia can cause behavioral and psychological symptoms:
- Control of improper activities is reduced (undressing in public settings)
- Visual and aural clues are misinterpreted (refuse treatment that they regard as an attack.)
- Short-term memory impairment (they frequently request items that have previously been delivered.)
- Inability or reduced ability to convey requirements (They wander since they are lonesome, afraid, or searching for someone or something.)
Assessment
Patients will need a complete evaluation, which will include a medical and mental health history, psychological condition, a thorough physical examination, and any further investigations. And if there is any disease, it should be taken care of.
Non-pharmacological techniques should always be considered before contemplating particular prescription medication, notably antipsychotics.
Multiple treatments for a single patient are more likely to be beneficial than a single method. Therefore, in complicated or difficult-to-treat patients, a mix of appropriate physical healthcare along with psychological and pharmaceutical therapies may be necessary.
A comprehensive medication evaluation will aid in eliminating drugs that may be causing or aggravating the BPSD.
Non-Pharmacological Treatments
Unrelieved pain, other ailments or infections, issues with hearing and vision, adverse medicine effects, and environmental variables such as alterations in routine can all cause behavioral and psychological signs of dementia.
Before resorting to medicine, it is critical to address these problems first. It is frequently feasible to avoid the usage of medications entirely by reducing discomfort and agitation. Here are some examples of treatments that can be used for behavioral disturbance in people living with dementia:
- Cognitive Behavioral Therapy (CBT) – may help with adjusting to the initial assessment, planning forward, and addressing depression in those with early-stage dementia. These treatments may be especially beneficial during the initial diagnosis.
- Caregivers may benefit from psychotherapy and psycho-educational – programs that help them deal with aiding the person with dementia while also maintaining their individual health wellness.
- Behavior Management Therapy – might help people living with dementia with problematic behavioral patterns. Roaming, anger, and persistent questioning are examples of such behaviors.
- Environmental modification – support innovative ways to dementia symptoms that focus on the individual with dementia’s surroundings. The optimum setting for them is something that is calm, consistent, and known.
- Dementia support networks – can assist people in forming valuable, supportive groups and recognizing the full range of possible support services if and when needed. Several Dementia Caregiver Support Groups can help.
- Memory training and the use of external memory tools can help a person with dementia in the initial stages improve their cognitive performance and independence.
Pharmacological Treatments
Drug prescription in psychiatric patients has evolved in a disorganized and informal way throughout the years. As a result, patients have been exposed to a wide variety of medications, some of which have serious adverse effects.
In the United States, medications to control behavioral disturbances are prohibited unless there is convincing evidence that psychiatric treatments have been attempted and proven to be ineffective.
However, a multitude of drug types, particularly antipsychotics, have been tried, and they are discussed here in detail.
1. Antipsychotic Drugs
Antipsychotic medicines may be used for people living with dementia who exhibit aggressive behavior or psychosis. However, this is normally only done after other medications, such as antidepressants, anti-dementia, and anticonvulsants, have been attempted.
Antipsychotic medications are used to treat individuals who have significant anxiety, aggressiveness, or stress of psychotic symptoms such as hallucinations and delusions. They are usually only used as a last option, including when the individual or others around them are in imminent danger.
Antipsychotics can help some people minimize the frequency or severity of these disturbances. However, they come with substantial dangers and negative impacts, and the doctor must examine them before prescribing.
Only a specialized doctor should write the initial antipsychotic prescription. This is frequently a psychiatrist for the elderly, a geriatrician, or a general practitioner specializing in dementia.
In most people, antipsychotic medications can be safely decreased and ultimately withdrawn after three months with no aggravation of behavioral problems.
Antipsychotics are divided into two categories: typical and atypical.
The newer atypical antipsychotics are frequently favored because they have fewer movement-related adverse effects, such as tremors, muscular rigidity, and uncontrollable tongue and mouth movements. These include aripiprazole, quetiapine, risperidone and olanzapine.
2. Antidepressants
Antidepressants including sertraline, citalopram, mirtazapine, and trazodone are frequently recommended to people living with dementia who have mood and behavior disturbances.
Antidepressants may assist not just in improving a chronically depressed mood but also in regulating irritability and fast mood swings that are common in dementia and after a stroke. The doctor will normally prescribe taking antidepressant medications for at least six months once begun. It is critical that they are taken on a regular basis without missing any doses for them to be effective.
Citalopram, in particular, has been shown to aid with agitation. The amount of citalopram required to lessen agitation, on the other hand, may have serious adverse effects, including an increased risk of falling and a dangerously erratic pulse. Citalopram is not approved to treat agitation as a result of this.
On the other hand, some doctors may give citalopram at lesser dosages if they believe the person’s agitation is caused in part by depression or anxiety.
Mood improvement usually requires at least 2 – 3 weeks, if not longer. Within a few days of commencing medication, side effects such as gastrointestinal discomfort may emerge. Over time, these effects normally fade.
3. Anti-dementia Drugs
Donepezil, rivastigmine, and galantamine are AChE inhibitors. People living with Alzheimer’s disease, Lewy body dementia, Parkinson’s dementia, or just any other dementia that contains one of these categories (such as Alzheimer’s disease and vascular dementia) are commonly given these. They are usually administered shortly after a diagnosis of dementia and sustained all through the person’s dementia.
According to some evidence, these medicines may also minimize agitation in individuals with mild to severe Alzheimer’s disease. They may also assist individuals with Lewy body dementia in alleviating hallucinations and delusions. However, since most individuals with these kinds of dementia are already consuming these medications, they are rarely recommended, especially for this purpose.
Memantine is another medicine used to treat memory and cognitive issues. As dementia advances, this is often administered in conjunction with an AChE inhibitor.
Memantine is a medicine that is occasionally used to treat aggressiveness or psychosis, and it has fewer risks and adverse effects than antipsychotic medications. However, this should not be prescribed if the patient has vascular dementia.
4. Anticonvulsants
Anticonvulsants are medications that are used to keep individuals with epilepsy from having fits. These are sometimes used to treat agitation and aggressiveness in people living with dementia. They are not suggested for this purpose since there is little proof that they will be beneficial and have significant negative effects.
Final Thoughts
As dementia advances, a person’s mental and emotional state will change. As a result, some activities and tasks will become even more challenging.
Such shifts can be distressing for both those living with dementia and those who care for them. It’s sometimes tough to figure out why they occur. It’s critical to try to understand the other person’s perspective rather than blaming them for their actions.
Without the use of medicine, most issues resolve after a few weeks of diagnosing the problem and implementing basic modifications. However, small adjustments can have a significant effect, such as spending extra time with the individual or modifying their daily routine.
The doctor might have to prescribe drugs if the person’s difficulties inevitably cause them extreme suffering or expose them or others to danger of bodily damage. Even so, medications should be used in conjunction with individualized assistance and non-drug techniques that are tailored to the individual’s requirements.
If a doctor believes that a particular drug will be beneficial, they should discuss it with the person and, ideally, with their caregiver. They should clarify the specific problems the medicine is meant to treat and any potential side effects.
And to avoid accidental overdosing, medicines must always be used as recommended by a doctor and kept safe and secure.
It is important to note that all medications have multiple names or at least two – a generic term that defines the active ingredient and a commercial name that varies depending on the manufacturer.
References
- https://pubmed.ncbi.nlm.nih.gov/16675752/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686333/
- https://pubmed.ncbi.nlm.nih.gov/15881470/
- https://www.dementia.org.au/information/for-health-professionals/clinical-resources/non-pharmacological-treatments
- https://bpac.org.nz/2020/bpsd.aspx
- https://www.dementia.org.au/sites/default/files/helpsheets/Helpsheet-DementiaQandA04-DrugsUsedToRelieveBehaviouralAndPsychologicalSympoms_english.pdf
- https://www.alzheimers.org.uk/about-dementia/treatments/drugs/antipsychotic-drugs#content-start
