Assessment and management of behavioral and psychological symptoms of dementia

Helen C Kales, Laura N Gitlin, Constantine G Lyketsos, Helen C Kales, Laura N Gitlin, Constantine G Lyketsos

Abstract

Behavioral and psychological symptoms of dementia include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of inappropriate behaviors. One or more of these symptoms will affect nearly all people with dementia over the course of their illness. These symptoms are among the most complex, stressful, and costly aspects of care, and they lead to a myriad of poor patient health outcomes, healthcare problems, and income loss for family care givers. The causes include neurobiologically related disease factors; unmet needs; care giver factors; environmental triggers; and interactions of individual, care giver, and environmental factors. The complexity of these symptoms means that there is no "one size fits all solution," and approaches tailored to the patient and the care giver are needed. Non-pharmacologic approaches should be used first line, although several exceptions are discussed. Non-pharmacologic approaches with the strongest evidence base involve family care giver interventions. Regarding pharmacologic treatments, antipsychotics have the strongest evidence base, although the risk to benefit ratio is a concern. An approach to integrating non-pharmacologic and pharmacologic treatments is described. Finally, the paradigm shift needed to fully institute tailored treatments for people and families dealing with these symptoms in the community is discussed.

Conflict of interest statement

Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: HCK has received grant support through the National Institutes of Health (NIH) and Department of Veterans Affairs. LNG has received grant support through NIH, Alzheimer’s Association; she is a member on the FallAdvisory Committee for Phillips Lifeline and has received honorariums for various speaking engagements. CGL has received grant support (research or continuing medical education) from the National Institute of Mental Health, the National Institute on Aging, Associated Jewish Federation of Baltimore, Weinberg Foundation, Forest, GlaxoSmithKline, Eisai, Pfizer, AstraZeneca, Lilly, Ortho-McNeil, Bristol-Myers, Novartis, the National Football League (NFL), Elan, and Functional Neuromodulation;he is a consultant or adviser for AstraZeneca, GlaxoSmithKline, Eisai, Novartis, Forest, Supernus, Adlyfe, Takeda, Wyeth, Lundbeck, Merz, Lilly, Pfizer, Genentech, Elan, the NFL Players Association, NFL Benefits Office, Avanir, and Zinfandel and he has received honorariums or travel support from Pfizer, Forest, GlaxoSmithKline, and Health Monitor.

© BMJ Publishing Group Ltd 2015.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4784836/bin/kalh018295.f1_default.jpg
Fig 1 Conceptual model describing how interactions between the person with dementia, care giver, and environmental factors cause behavioral and psychological symptoms of dementia (BPSD)
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4784836/bin/kalh018295.f2_default.jpg
Fig 2 The DICE (describe, investigate, create, and evaluate) approach
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4784836/bin/kalh018295.f4_default.jpg
Fig 3 Modifiable causes of behavioral and psychological symptoms of dementia
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4784836/bin/kalh018295.f3_default.jpg
Fig 4 Examples of "create" interventions

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