Dr Joy Ratcliffe, Consultant Psychiatrist Dr Julie Colville, Clinical Psychologist

1. Behavioural and Psychological Symptoms of Dementia Non-pharmacological and pharmacological approaches Dr Joy Ratcliffe, Consultant Psychiatrist Dr Julie Colville, Clinical Psychologist Lorraine Smith, Advanced Practitioner Manchester Mental Health and Social Care Trust & CMFT

2. BPSD • What is it? • Heterogeneous group non- cognitive behaviours • Not a diagnostic category – but very important • Think as a list of disturbed behaviours e.g. • Wandering • Agitation • Sexually disinhibited behaviours • Aggression • Paranoia/suspicion • Eliciting psychological/psychiatric problems e.g. depression, anxiety, delusional ideas/psychosis • All adds to risk

3. BPSD • Behavioural and psychological symptoms of dementia (BPSD) are common • They can be problematic in clinical practice and can form a significant part of the day-to-day work of primary care teams, later life psychiatry teams. CMHTs, inpatient and community settings. • We need to improve recognition and management of BPSD • Improved management can have a positive impact on the quality of life of our patients and carers both at home and in nursing/residential setting s • Positive management may also delay 24hr care

4. BPSD - Prevalence • Vary widely • Approx 2/3rds will experience BPSD at any one time • Approx 1/3 in the ‘clinically significant ‘range • Can rise to 80% in care homes • 20% for BPSD in Alzheimer’s disease • BPSD tends to fluctuate with psycho-motor agitation most common and persistent

5. BPSD - Impact • BPSD rather than cognitive features are the major causes of care giving burden • Paranoia, aggression, disturbed sleep-wake cycles important drivers for 24hr care • BPSD also associated with worse outcome and illness progression • Adds significantly to direct and indirect care costs

6. Multiple Factors that influence Behaviour

7. Non Pharmacological management of BPSD – • Must be ‘collaborative’ - • Needs thorough Assessment - multiple factors • Need nursing home staff to input into assessment e.g. what do they know about their client? • Need staff e.g. Nursing Home to play key part e.g. ABCs - helps identify factors such as over/under stimulation, pain etc • Need staff to implement and monitor plans • Care Staff do need training in dementia • Need medical staff to ensure physical problems optimally treated e.g. infection, pain

8. Non Pharmacological management of BPSD • Understanding client’s history, lifestyle, culture and preferences, including their likes, dislikes, hobbies and interests. • Providing opportunities for the person to have conversations with other people. • Ensuring the person has the chance to try new things or take part in activities they enjoy. • Environmental factors-signage, lighting, photographs. • Reminiscence therapy.

9. Shared Care • Shared care plans to enhance communication and collaboration. • Discuss shared care plan.

10. Principle of Behaviour Management - Observing and Describing • What is happening • When does it happen • How often does it happen • Who is there when it’s happening • What is communication like • Why do you think it is happening • Any other observations

11. Principles of Behaviour Management- Contingencies • What are we targeting: • Frequency/ severity • High frequency/ low severity (lower consequences) • Low frequency/high severity (higher consequences) • High frequency/High severity (highest consequences) • What are ‘contingencies? e.g. positive and negative reinforcement

12. Biological Management • Treat underlying cause • Psychotropics? • Severity • Risk • Distress • Medical comorbidity / other meds esp vascular risks • Capacity • Views carers

13. Assessment • Delirium (caution not to miss hypoactive)? • PINCH ME (pain, infection, nutrition, constipation, hydration, medications, environment) • PAIN (physical / pain, activity related, iatrogenic, noise / environment)

14. START LOW GO SLOW • Review target symptoms and adverse effects • How long to treat for • Gradual withdrawal • Licensed?

15. Psychosis- risperidone (0.25-0.5mg bd), olanzapine (2.5-10mg), quetiapine (25-150mg) amisulpiride, aripiprazole, zuclopethixol • Aggression- as above, trazadone, clomethiazole • Agitation / anxiety- as above, citalopram, mirtazepine, memantine (AD), pregabalin • Depression- sertraline, citalopram, mirtazepine • Mania- valproate, lithium, antipsychotics • Apathy- sertraline, citalopram, cholinesterase inhibitor (D, R, G) • Sleep- temazapam, zopiclone, melantonin

16. Lewy Body Dementia (LBD) • CAUTION WITH ANTIPSYCHOTICS- quetiapine, aripiprazole, clozapine • 1st choice cholinesterase inhibitors • Clonazepam for REM sleep disorders

17. Vascular Dementia (VD) • Cholineterase inhibitors and memantine not licensed but majority of cases mixed AD / VD

18. Cholinesterase Inhibitors • Bradycardia • Prolonged QTC • LBBB • Gastric bleeding risk (pmhx, aspirin, NSAIDS, warfarin) • COPD / asthma • Epilepsy

19. Antipsychotics • ECG, QTC, other changes • Vascular risks • Increase cognitive impairment

20. Antidepressants • Sedation • GI bleeding • Na • Falls (inc SSRIs) • Citalopram –QTC, max dose 20mg

21. Anticonvulsants • Limited evidence • Adverse effects

22. Case Example • Case example • 75, female, vascular dementia, 24 hr care for 12 months • Complaints from care staff • agitation • ‘breathless’ hyperventilating, • ‘attention seeking’ – calling every 5 mins • Saying pain (but where?) • toileting – incontinent faeces • falls, (needing extra monitoring)

23. Case Example • PERSONAL – lived alone many years – over stimulated • - remove to quieter environment • DEMENTIA – vascular with periods disorientation unable to express distress (language) • - try and reorientation/reassurance spend time with

24. Case Example • PHYSICAL – incontinence = ‘overflow’ compacted, meds 2 x laxatives and codeine (opposite actions?), pain (unable to express) • - Elimination of acute physical illness as triggers for BPSD. Reviewed with Advanced Practitioner - GP to check pain and review meds, • FALLS – interaction meds Trazadone and codeine , over –sedated • - meds review, Falls Team, Physio, frame

25. Case Example • PSYCHOLOGICAL – fear of falling exacerbated by previous falls, highly anxious (premorbidly – calling ambulance, GP, police etc) • Ongoing assessment by Psychology, anxiety still prominent • Linked to disorientation and/or premorbid anxiety • Activity/distraction, optimal? • Co pharmacological treatments – optimally treated?