psikogeriatri ppt

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Behavioral and PsychologicalBehavioral and PsychologicalSymptoms of DementiaSymptoms of Dementia

BPSDBPSD

Behavioral and PsychologicalBehavioral and PsychologicalSymptoms of DementiaSymptoms of Dementia

BPSDBPSD

International Psychogeriatric AssociationInternational Psychogeriatric Association

20022002


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Estimates of Increasing Size of the

Elderly Population


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BPSDBPSD

BPSDBPSD

90% of patients affected by dementia willexperience Behaioral and Psychological

Symptoms of Dementia !BPSD" that areseere eno#gh to be labeled a problem atsome time d#ring the co#rse of their illness$

!ega et al$ &99'"


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DementiaDementia

DementiaDementiaDefinition Memory impairment, plus

Impairment in at least one other domain

Representing decline

Interfering with function

Not better accounted for by a number of otherconditions

DSM-IV-TR; APA 2000


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DementiaDementiaDementiaDementiaBPSDActivities of dailyliving

DementiaDementiaDementiaDementia

ehavioural and Psychological Symptoms of Dementia!

" heterogeneous range of psychological reactions,

psychiatric symptoms and behaviours resulting

from the presence of dementia

(ognitivedeficits


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Finkel 1996

Why Are BPSD Important?Why Are BPSD Important?Why Are BPSD Important?Why Are BPSD Important?

)hey res#lt in*

e#cess disability

increased hospitali$ation premature institutionali$ation

suffering for patient and caregiver

substantial increase in financial costs

Why Are BPSD Important?Why Are BPSD Important?Why Are BPSD Important?Why Are BPSD Important?


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(a#ses of BPSD(a#ses of BPSD(a#ses of BPSD(a#ses of BPSD

Intellect#al and cognitie changes

+ amnesia, agnosia, apraxia, aphasia,apathy

-e#rotransmitter dysf#nction

+ dopamine, serotonin, cholinergic,adrenergic, .ABA

Instinct#al behaiors #nder stress

+ territoriality + defensieness


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Diagnosis and Assessment of BPSDDiagnosis and Assessment of BPSDDiagnosis and Assessment of BPSDDiagnosis and Assessment of BPSD

Phenomenology is the basis of diagnosis

% Direct interview

% Direct observation

% Pro#y report% Measurements and scales

Need for accurate descriptions

&hin' of physical illness

&hin' of sensory impairment


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Variation With ype of DementiaVariation With ype of DementiaVariation With ype of DementiaVariation With ype of Dementia

Visual hallucinations are more common inVisual hallucinations are more common in

Diffuse Lewy Body DementiaDiffuse Lewy Body Dementia

Disinhibition symptoms occur early in theDisinhibition symptoms occur early in the

some of the Frontotemporal Dementiassome of the Frontotemporal Dementias Earlier onset of behavioral symptoms hasEarlier onset of behavioral symptoms has

been described in Huntingtons chorea,been described in Huntingtons chorea,

Creutzfeldt-Jacob disease and Picks diseaseCreutzfeldt-Jacob disease and Picks disease


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PI/(/S framewor to #nderstand BPSDPI/(/S framewor to #nderstand BPSDPI/(/S framewor to #nderstand BPSDPI/(/S framewor to #nderstand BPSD

PPhysical problem or discomfort

IIntellect#al1cognitie changes

EEmotional

CCapacities

EEnironment

SSocial1c#lt#ral


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/stimated fre#ency of common BPSD/stimated fre#ency of common BPSD/stimated fre#ency of common BPSD/stimated fre#ency of common BPSD

Agitation #p to 34%

5andering #p to '0%

Depression #p to 40%

Psychosis #p to 60% Screaming #p to 24%

Aggression #p to 20%

Sex#al Disinhibition #p to &0%

!ega, (#mming et al$&99'"


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Depression

Psychosis

"ltered circadianrhythms

"n#iety

"gitation

Symptom !omple"es ofSymptom !omple"es ofBPSDBPSDSymptom !omple"es ofSymptom !omple"es ofBPSDBPSD


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Psychosis in BPSDPsychosis in BPSDPsychosis in BPSDPsychosis in BPSDPsychosis inPsychosis in

BPSDBPSD

Psychosis inPsychosis in

BPSDBPSD


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(este, )in'el *+++

(haracteristic symptoms

Presence of one or more of the following

symptoms!

visual or auditory hallucinations

delusions

Primary diagnosis

"ll the criteria for dementia of the "l$heimer

type are met-

*)or other dementias, such as vascular dementia, .riterion

will need to be modified appropriately

Diagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of AD


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Diagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of ADDiagnostic !riteria for Psychosis of AD

D#ration and seerity&he psychotic symptom/s0 have been present,at least intermittently, for 1 month or longer

Symptoms are severe enough to cause somedisruption in patients2 and3or others2functioning


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Associated feat#res

5ith agitation*

when there is evidence, from history or e#amination, of prominent

agitation with or without physical aggression

5ith negatie symptoms*when prominent negative symptoms, such as apathy, affective

flattening, avolition or motor retardation are present

5ith depression*

when prominent depressive symptoms, such as depressed mood,

insomnia or hypersomnia, feelings of worthlessness or e#cessiveinappropriate guilt, or recurrent thoughts of death are present

Jeste, Finkel 2000



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Depression in BPSDDepression in BPSDDepression in BPSDDepression in BPSD


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Prevalence of Depression in DementiaPrevalence of Depression in DementiaPrevalence of Depression in DementiaPrevalence of Depression in Dementia

Depression has long been recogni$ed as ama4or co5morbidity of dementia syndromes

Prevalence of depression in D"& +65*+6,

but lac'ing diagnostic criteria specific fordepression in dementia, most studies reportprevalence of depressive symptoms

Prevalence rates in 7ascular Dementia 186 5

9:6


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Depression as the #irst Sign of DementiaDepression as the #irst Sign of DementiaDepression as the #irst Sign of DementiaDepression as the #irst Sign of Dementia

Patients initially diagnosed with depressive

pseudodementia or ;reversible dementia; may not

achieve complete cognitive recovery following

remission of depression

"n average of 115*:6 of patients with initiallyreversible dementia become irreversibly demented

every year

Irreversible dementia begins to be diagnosed about

two years after the initial recovery from depression


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!linical!linical

!haracteristics of Depression in BPSD!haracteristics of Depression in BPSD!linical!linical

!haracteristics of Depression in BPSD!haracteristics of Depression in BPSD

Depressive symptoms in dementia patients oftenfluctuate

Depressed patients with D"& e#hibited more self5

pity, re4ection sensitivity, anhedonia andpsychomotor disturbance than depressed olderpatients without dementia

Ma4or depression in D"& is associated with anincreased mortality rate, but no acceleration ofcognitive decline


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Etiology of Depression in DementiaEtiology of Depression in DementiaEtiology of Depression in DementiaEtiology of Depression in Dementia

a7or depression in AD has been associated with*

increased degeneration of brainstem aminergic nuclei,

particularly the locus coeruleus

Relative preservation of the cholinergic nucleus basalis

of Meynert

No increase in the numbers of senile plaI""

?nvironmental and psychosocial factors


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reatment $esponse ofreatment $esponse of

Depression in DementiaDepression in Dementia

reatment $esponse ofreatment $esponse of

Depression in DementiaDepression in Dementia .an be effectively treated with antidepressants and

behavioral techni


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!ircadian $hythm!ircadian $hythm

Distur%ancesDistur%ances




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Disturbances of sleep and day5night reversalsare common

Sleep disturbances may be more common incertain dementias, such as vascular dementia,dementia with @ewy odies and supranuclear

palsy, compared to those found in"l$heimer2s disease

"ldrich, )oster, et al 18A8

"haron5Peret$, Masiah, et al 1881

oeve et al, *++1


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)unctional and anatomic changes occur inthe suprachiasmatic nucleus in dementias

"lterations of the daily rhythm of serummelatonin have been correlated to somecases of sleep disturbances in "l$heimer2sdisease

Stopa, 7olicer, et al 1888

Bchida, C'amoto, et al 188


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-onpharmacologic therapies incl#de*

'eeping patients awa'e during the day withvarious e#ternal stimuli

sometimes structuring short nap after lunch toavoid sundowning

early evening activities

stimulus control at night

Ewhite noiseF

bright light e#posure(ean5@ouis, Gi$i, et al

188A


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Pharmacologic interventions includemelatonin, nonben$odia$epine hypnotics eg$olpidem, ben$odia$epines, tra$odone

.aregiver interventions include! educationalprograms, respite, and assistance with theirown sleep needs

(ean5louis, Gi$i, et al 188A

@y'etos, 7eiel et al 1888

Chashi, C'amoto, et al 1888

Shelton and >oc'ing 188H

7an Someren, essler, et al 188H


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Agitation in BPSDAgitation in BPSDAgitation in BPSDAgitation in BPSD


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AgitationAgitationAgitationAgitation

Some patients have symptoms that do not neatlyfit into the better defined symptom comple#es ofPSD /eg psychosis, depression or an#iety0

&hese symptoms are consigned to the Egrab5bagFcategory of agitation

"gitation can be defined as inappropriate verbal,vocal or motor activity that is not 4udged by anoutside observer to result directly from the needsor confusion of the person

oss, Jeiner, et al 188H

.ohen5Mansfield and illig, 18A


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Agitation Symptoms & IAgitation Symptoms & IAgitation Symptoms & IAgitation Symptoms & I

Physically -on+Aggressie Keneral Restlessness

Repetitive Mannerisms

Pacing

>iding Cb4ects Inappropriate >andling

Shadowing

?scaping protectedenvironment

InappropriateDressing3Bndressing

.ohen5Mansfield, 18A8


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Agitation Symptoms & IIAgitation Symptoms & IIAgitation Symptoms & IIAgitation Symptoms & II

Physically Aggressie

>itting

Pushing

Scratching

Krabbing

ic'ing

iting Spitting .ohen5Mansfield, 18A8


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Agitation Symptoms & IIIAgitation Symptoms & IIIAgitation Symptoms & IIIAgitation Symptoms & III

8erbally -on+Aggressie

Negativism

.hanting

Repetitive Sentences .onstant Interruptions

.onstant Re


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Agitation Symptoms & IVAgitation Symptoms & IVAgitation Symptoms & IVAgitation Symptoms & IV

8erbally Aggressie

Screaming

.ursing

&emper Cutbursts

Socially Inappropriate .ommentary

.ohen5Mansfield, 18A8


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Disinhi%ition SyndromeDisinhi%ition SyndromeDisinhi%ition SyndromeDisinhi%ition Syndrome

Impulsive and inappropriate behaviors

?motionally unstable

Poor insight and 4udgement


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Disinhi%ition SyndromeDisinhi%ition SyndromeDisinhi%ition SyndromeDisinhi%ition Syndrome

/continued0

Symptoms include crying, euphoria,verbal aggression, physical aggression,

self5destructive behavior, se#ualdisinhibition, intrusiveness, wandering,shoplifting, impulse buying and otherunrestrained behaviors


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AggressionAggressionAggressionAggression

1*6 of patients showed aggressiveepisodes /=6 with verbal aggression,H6 with physical aggression0 during

the preceding 9 wee's Physical aggression is significantly

associated with more fre


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AggressionAggressionAggressionAggression Symptom comple#es include!

"ggression associated with delirium

"ggression associated with depression

"ggression associated with psychosisSpontaneous disinhibited aggression

Reactive aggression associated withpersonal care, discomfort


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!atastrophic $eactions!atastrophic $eactions!atastrophic $eactions!atastrophic $eactions

Sudden, e#cessive emotional response orphysical behavior

Cccur in appro#imately 9+6 of mild5moderatelyimpaired dementia patients

During neuropsychological evaluation, 16 ofdementia patients demonstrated catastrophicreactions

.an be precipitated by other PSD such as

misperception, hallucinations or delusions


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An"ietyAn"ietySymptomsSymptomsin BPSDin BPSD

An"ietyAn"ietySymptomsSymptoms

in BPSDin BPSD


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!linical !haracteristics of An"iety!linical !haracteristics of An"ietySymptoms in BPSDSymptoms in BPSD

!linical !haracteristics of An"iety!linical !haracteristics of An"ietySymptoms in BPSDSymptoms in BPSD

No specific definition of an#iety in PSD is available

&he most common clinical forms are!

% Kenerali$ed "n#iety Disorder type symptoms

% Kodot syndrome repeatedly as'ing


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Possible Biological Correlates of AnxietyPossible Biological Correlates of AnxietySymptoms in DementiaSymptoms in Dementia

Possible Biological Correlates of AnxietyPossible Biological Correlates of AnxietySymptoms in DementiaSymptoms in Dementia

Decrease concentration of =5>& and =5>I""in corte#, basal ganglia and brainstem

Neuronal loss in raphe nucleus Decrease in K"" activity

Na$arali et al,188*

Reini'ainen et al, 18AA


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'am&A'am&A Items that DifferentiateItems that DifferentiateBet(een AD&)AD and AD&!ontrolsBet(een AD&)AD and AD&!ontrols

'am&A'am&A Items that DifferentiateItems that DifferentiateBet(een AD&)AD and AD&!ontrolsBet(een AD&)AD and AD&!ontrols

"n#ious Mood

&ension

)ears Insomnia

MuscularSymptoms

Somatic Symptoms

.ardiovascularSymptoms

RespiratorySymptoms

KastrointestinalSymptoms

"utonomicSymptoms

.hemerins'y ?, Petraca K, Manes ) et al, 188A


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reatment ofreatment of

BPSDBPSD

reatment ofreatment of

BPSDBPSD


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BPSD* +onpharmacologic herapyBPSD* +onpharmacologic herapyBPSD* +onpharmacologic herapyBPSD* +onpharmacologic herapy

?nvironmental modifications such asmusic, white noise, plants, animals

Spea' slowly, 'eep commands simple and

positive, use gestures, gentle touch ehavioral management techni


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If Pharmacological herapy Is +eeded*If Pharmacological herapy Is +eeded*If Pharmacological herapy Is +eeded*If Pharmacological herapy Is +eeded*

@oo' for symptom comple#es such as depression,psychosis or an#iety to guide initial choice of agent

If enlightened empiric therapy is needed, chose agentsthat minimi$e side5effect potential and ma#imi$echance of efficacy

In most situations, medications should be given inlower doses than are typically recommended for anadult population >owever, it is noteworthy that theelderly are heterogeneous and the range of medicationdosage is substantial

Ideally, use agents with demonstrable efficacy as firstline agents

If Pharmacological herapy Is +eeded*If Pharmacological herapy Is +eeded*If Pharmacological herapy Is +eeded*If Pharmacological herapy Is +eeded*

) t t f i t t h ti t)reatment of persistent ps chotic s mptom

)reatment of persistent psychotic symptoms)reatment of persistent psychotic symptoms


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)reatment of persistent psychotic symptom)reatment of persistent psychotic symptom

and aggressionand aggression

)reatment of persistent psychotic symptoms)reatment of persistent psychotic symptoms

and aggressionand aggression

Best choices are* risperidone,Best choices are* risperidone,

olanapine, #etiapineolanapine, #etiapine

All hae significant side+effectsAll hae significant side+effects

++ :isperidone* watch for /PS:isperidone* watch for /PS+ ;lanapine* sedation, anticholinergic S/,+ ;lanapine* sedation, anticholinergic S/,

increased asc#lar ris factorsincreased asc#lar ris factors

+

risperidonerisperidone


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Best medications for anxiety symptomsBest medications for anxiety symptomsBest medications for anxiety symptomsBest medications for anxiety symptoms

SS:I antidepressants are now first linetreatment for anxiety disorders

+ 5ill tae a few wees to wor f#lly+ 5atch for .I symptoms, headaches, hyponatremia

ay consider a cholinesterase inhibitor ifpatient not already taing

+ 5ill tae a few wees to wor f#lly

+ Screen for b#ndle branch bloc

+ 5atch for .I symptoms, sleep dist#rbance, worsening ofagitation


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Best medications for anxiety symptomsBest medications for anxiety symptomsBest medications for anxiety symptomsBest medications for anxiety symptoms

ay also consider )raodone for itssedating effects

+ 5atch for hypotension, oer+sedation,priapism

If anxiety is specific to occasionalsit#ations, consider p#nct#al #se ofloraepam !ie$ 5eely bath"

++ ay ca#se falls, worsening of disinhibiteday ca#se falls, worsening of disinhibitedbehaio#r, conf#sion and memory problemsbehaio#r, conf#sion and memory problems


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Best medication for depressionBest medication for depressionBest medication for depressionBest medication for depression SS:Is !eg$ (italopram, sertraline",

moclobemide, enlafaxine, orb#proprion #s#ally considered first

+ ?ow anticholinergic actiity and low

potential for dr#g interactions

Selection based on preio#s response totreatment, medical problem list anddr#g interactions$


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;ther treatments for depressio;ther treatments for depression;ther treatments for depression;ther treatments for depression @or ery seere or psychotic depression

consider electrocon#lsie therapy$

@or rec#rrent depression of bipolarillness, patient will re#ire a moodstabilier first !to aoid switch intomania"


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)reatment with antidepressant)reatment with antidepressant)reatment with antidepressant)reatment with antidepressants )itration according to therape#tic benefits and

side effects* #s#ally taes at least one month

Ade#ate trial* wees at maxim#m toleratedor recommended dose if no response '+Cwees if partial response

D#ration of treatment* -o specific eidence ford#ration of treatment in the presence of dementia b#tclinicians follow general recommendations #nless there isgood reason not to

2 years or more !=" if rec#rrent depressie

disorder

)reatment of manic lie symptoms)reatment of manic lie symptoms

)reatment of manic lie symptoms)reatment of manic+lie symptoms


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)reatment of manic+lie symptoms)reatment of manic+lie symptoms

!ery limited data"!ery limited data"

)reatment of manic+lie symptoms)reatment of manic+lie symptoms

!ery limited data"!ery limited data"

If well established diagnosis of bipolarillness prior to dementia, low doselithi#m with appropriated geriatricblood leels !0$+0$' m/1?" may be

best treatment b#t re#ires closemonitoring

@or new onset of manic+lie symtoms,consider alproic acid or

carbamaepine

: f b h i l bl d t:x of behaioral problems d#e to

:x of behaioral problems d#e to:x of behaioral problems d#e to


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?ewy Body dementia?ewy Body dementia


?ewy Body dementia?ewy Body dementia

(holinesterase inhibitors are now firstline of treatment$ -eed to try oerseeral wees$

If ineffectie or too early in treatment,consider traodone !watch BP" and lowdoses of loraepam or oxaepam

If antipsychotic medication necessarydoc#ment ris with SD and consider

low doses of #etiapine$


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hen it is necessary to decrease sex#al drie !rhen it is necessary to decrease sex#al drie !rhen it is necessary to decrease sex#al drie !rhen it is necessary to decrease sex#al drie !r

(onsider anti+androgens, SS:Is or anti+psychotics with informed consent

Aoid benodiaepines and rememberthat traodone can ca#se priapism


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www$ipa+online$orgwww$ipa+online$org


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SummarySummarySummarySummary ehavioral and psychological

symptoms of dementia are common

PSD have a ma4or negative impact onthe patients, their families andcaregivers

&he behavioral and psychologicalsymptoms respond to therapy, and byimproving our e#pertise we can help

our patients


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$eferences$eferences$eferences$eferences

"ldrich, M S, N @ )oster, et al /18A80 ESleep abnormalities in progressive supranuclear palsyF "nnals CfNeurology 24/0! =HH5A1

"haron5Peret$, (, " Masiah, et al /18810 ;Sleep5wa'e cycles in multi5infarct dementia and dementia of the"l$heimer type; Neurology 91/1+0! 1158

Stopa, ? K, @ 7olicer, et al /18880 EPathologic evaluation of the human suprachiasmatic nucleusin severe dementiaF ( Neuropathol ?#p Neurol =A/10! *85:8

Bchida, , N C'amoto, et al /1880 EDaily rhythm of serum melatonin in patients with dementiaof the degenerate typeF rain Research H1H/15*0! 1=958

(ean5@ouis, K, ) Gi$i, et al /188A0 ;?ffects of melatonin in two individualswith "l$heimerLsdisease; Percept Mot S'ills AH/10! ::158

@y'etsos, . K, @ @indell 7eiel, et al /18880 ;" randomi$ed, controlled trial of bright light therapyfor agitated behaviors in dementia patients residing in long5term care; Int ( Keriatr Psychiatry 19/H0! =*+5=

Chashi, , N C'amoto, et al /18880 ;Daily rhythm of serum melatonin levels and effect of lighte#posure in patients with dementia of the "l$heimerLs type; iol Psychiatry 9=/1*0! 195=*

Shelton, P S and @ >oc'ing /188H0 ;Golpidem for dementia5related insomnia and

nighttime wandering; "nnals Cf Pharmacotherapy :1/:0! :185**


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$eferences$eferences$eferences$eferences

7an Someren, ? (, " essler, et al /188H0 ;Indirect bright light improves circadian rest5activity rhythm disturbancesin demented patients; iological Psychiatry 91/80! 8==5: Note that this study was done on individuals clinicallydiagnosed as probable "l$heimerLs disease, multi5infarct dementia, dementia associated with alcoholism, or normal

pressure hydrocephalus

7an Someren, ? (, M Mirmiran, et al /188:0 ;Non5pharmacological treatment of sleep and wa'e disturbances in agingand "l$heimerLs disease! chronobiological perspectives; ehav rain Res =H/*0! *:=5=:

oss, ?, M Jeiner, et al /188H0 ;"ssessing patterns of agitation in "l$heimerLs disease patients withthe .ohen5Mansfield "gitation Inventory &he "l$heimerLs Disease .ooperative Study; "l$heimerDis "ssoc Disord 11/Suppl *0! S9=5=+

Rowe, M and D "lfred /18880 ;&he effectiveness of slow5stro'e massage in diffusing agitated behaviorsin individuals with "l$heimerLs disease; ( Kerontol Nurs *=/0! **5:9

Kerdner, @ " and ? " Swanson /188:0 ;?ffects of individuali$ed music on confused and agitatedelderly patients; "rch Psychiatr Nurs H/=0! *A9581

urgio, @, Scilley, et al /1880 ;?nvironmental ;white noise;! an intervention for verbally agitatednursing home residents; ( Kerontol Psychol Sci Soc Sci =1/0! :95H:

Denney, " /188H0 ;uiet music "n intervention for mealtime agitationO; ( Kerontol Nurs *:/H0! 15*:

@y'etsos . K et al/*++10 ENeuropsychiatric disturbance in "l$heimerLs disease clusters into three groups! the .ache.ounty studyF Int ( Keriatr Psychiatry 1/110!1+9:5=:

Porsteinsson "P, &ariot PN, et al /*++10 EPlacebo5controlled study of divalproe# sodium for agitation in dementiaF "m (Keriatr Psychiatry Jinter 8 /10!=A5

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