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Neuropsychiatric Symptoms of Dementia

Neuropsychiatric Symptoms of Dementia. Dr. Dallas Seitz MD FRCPC Assistant Professor, Department of Psychiatry Queen’s University. Objectives. 1 .) Understand the prevalence and importance of neuropsychiatric symptoms (NPS) of dementia

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Neuropsychiatric Symptoms of Dementia

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  1. NeuropsychiatricSymptomsofDementia Dr. Dallas Seitz MD FRCPC Assistant Professor, Department of Psychiatry Queen’s University

  2. Objectives 1.) Understand the prevalence and importance of neuropsychiatric symptoms (NPS) of dementia 2.) Review the biological and psychosocial factors associated with the development of NPS 3.) Review the evidence for pharmacological and non-pharmacological treatments for NPS

  3. Neuropsychiatric Symptoms • Non-cognitive symptoms associated with dementia • Also known as Behavioral and Psychological Symptoms of Dementia (BPSD) • International Psychogeriatrics Association 1996 “Signs and symptoms of disturbed perception, thought content, mood, or behavior that frequently occur in patients with dementia”1 1. Finkel, IntPsychogeriatr, 1996; 8(suppl 3):497-500

  4. What are Neuropsychiatric Symptoms? • Agitation2: • Restlessness • Requests for help or repetitive questioning • Screaming or vocalizations • Hitting, pushing, kicking • Sexually disinhibited behavior • Delusions1 • Hallucinations • Anxiety • Elevated mood • Apathy • Depression • Irritability • Sleep Changes 1. Cummings, Neurology, 1994 2. Cohen-Mansfield, J Geronotol, 1989

  5. Clusters of Neuropsychiatric Symptoms • Cohen-Mansfield Agitation Inventory (CMAI)1: • Verbal agitation (yelling, repetitive vocalizations) • Non-aggressive physical agitation (restlessness, pacing) • Aggressive physical agitation • Neuropsychiatric Inventory (NPI)2: • Psychotic symptoms (delusions/hallucinations) • Mood/Apathy (depression/apathy/eating/sleep) • Hyperactivity (agitation/irritability/euphoria/disinhibition) • 1. Cohen-Mansfield, J Gerontol, 1989 • 2. Aalten, Dement GeriatrCognDisord, 2003

  6. Prevalence of NPS Prevalence in Past 30 Days Lyketsos, JAMA, 2002

  7. Prevalence of NPS in Long-Term Care • Prevalence of NPS2: • Psychosis 15 – 30% • Depression: 30 – 50% • Physical agitation: 30% • Aggression: 10 – 20% • 60% of individuals LTC settings have dementia1 • Overall prevalence of NPS: • Median prevalence of any NPS: 78% 1. Seitz, IntPsychogeriatr, 2010 2. Zuidema, J Geriatr Psych Neurol, 2007

  8. Persistence of NPS • Neuropsychiatric symptoms are often chronic1,2 • More likely to persist: delusions, depression, aberrant motor behavior • Less likely to persist: hallucinations, disinhibition Steinberg, Int J Geriatr Psychiatry, 2004 Aalten, Int J Geriatr Psychiatry, 2005

  9. Associations with Stage of Illness Percentage of Individuals with Symptoms Chen, Am J Geriatr Psychiatry, 2000

  10. Impact of Neuropsychiatric Symptoms • Increased patient and caregiver distress1 • Increased risk for institutionalization • More rapid functional decline • Increased risk of mortality • Economic costs Bannerjee, J NeurolNeurosurg Psychiatry, 2006

  11. Causes of Neuropsychiatric Symptoms • Biological • Psychological and social

  12. Biological Correlates of NPS • Neurotransmitter changes in acetylcholine, dopamine, noradrenergic, serotonin and GABA1 • Volume loss in certain brain regions associated with NPS2,3 • Decrease metabolism in frontal and cingulate cortex associated with psychotic symptoms4 • Lanari, Mech Aging Develop, 2006 • Rosen, Brain, 2005 • Bruen, Brain, 2005 • Sultzer, Am J Psychiatry, 2003

  13. Psychological Theories of NPS • Lowered Stress Threshold1 • Learning Theory2 • Unmet needs  Tailored interventions3 • Verbal agitation – depression, loneliness • Physically non-aggressive agitation - stimulation • Physically aggressive agitation – avoiding discomfort Hall, Arch Psych Nurs, 1987 Cohen-Mansfield, Am J Geriatr Psych, 2001 Cohen-Mansfield, Am Care Quarterly, 2000

  14. Understanding Neuropsychiatric Symptoms • Kitwood’s Framework for Personhood in Dementia1 • SD = P + B + H + NI + SP • SD = manifestation of dementia • Personality – previous coping strategies • Biography – other challenges presented in life • Health– sensory impairment • Neuropathological impairment – location, type, severity • Social psychology – environmental effects on sense of safety, value and personal being 1. Kitwood, Int J GeriatrPsychiatry, 1993

  15. Management of Neuropsychiatric Symptoms • Differential Diagnosis: • Delirium (medication-induced, other causes) • Depression • Pain or discomfort 1. Sink, JAMA, 2005

  16. Assessment of NPS • Assessment of behaviors • What are the risks associated with the behavior? • To patient, caregivers/staff, other individuals • What is the behavior? • E.g. using instrument such as CMAI or NPI • What type of dementia does the individual have? • What is the stage of dementia? • What are the goals of care?

  17. Assessment • ABC Approach • Antecedents to the behavior (i.e. during care) • Behavioral charting using Dementia Observation System DOS • Behaviors (what was the behavior?) • Consequences (what was the response to the behavior)

  18. General Principles To Managing NPS • Non-pharmacological treatments should be used first whenever available • Even when NPS are caused by specific etiologies (pain, depression, psychosis) non-pharmacological interventions should be utilized with medications • All non-pharmacological interventions work best when tailored to individual needs and background • Family and caregivers are key collaborators and need to involved in treatment planning IPA BPSD Guide, Module 5, 2010

  19. Non-Pharmacological or Psychosocial Treatments • Training caregivers or staff in behavioral management strategies and communication1,2 • Participation in pleasant events • Exercise • Music • Sensory stimulation (e.g. touch, Snoezelen, aromatherapy) • Appear to be well-tolerated and not associated with increased risk of mortality Cohen-Mansfield, Am J Geriatr Psychiatry, 2001 Livingston, Am J Psychiatry, 2005

  20. Limitations of Psychosocial Treatments • Modest effects of treatments • Effects size = 0.2 – 0.5 for many interventions • Limited access to programs and human resources necessary for implement • May required prolonged and sustained implementation for effects • Effectiveness for aggression and psychosis may be limited • Agitation, depressive symptoms may be more likely to respond

  21. Resources • Canadian Coalition for Seniors Mental Health • www.ccsmh.ca • Murray Alzheimer Research and Education Program • www.marep.uwaterloo.ca • Alzheimer’s Society • www.alzheimer.ca

  22. Resources • International Psychogeriatric Association BPSD Guides www.ipa-online.org

  23. Links to Materials • Webinars on Neuropsychiatric Symptoms • Assessment and Nonpharmacological Management • Pharmacological Management • Treatment Tool • CCSMH Pocket Card • www.dalllasseitz.webs.com

  24. Acknowledgments • Funding: • Canadian Institutes of Health Research: KRS#103345 KAL#114493 • Clinician Scientist Salary Award, Queen’s University

  25. Thank you • Questions?

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