Behavioral and Psychologic
Symptoms of Dementia

Behavioral and psychologic symptoms of dementia include intolerable, disruptive actions (eg, wandering, yelling, throwing, hitting) that frequently occur in patients with dementia. If such symptoms develop, patients should be promptly evaluated to identify potentially reversible contributing factors. Treatment is best accomplished with nondrug therapies, but drugs are often used; psychosis and aggression are treated with drugs.

Geriatric Essentials

• Sudden onset of behavioral and psychologic symptoms of dementia (BPSD) often indicates another disorder such as a UTI, heart failure, or pain. If a change in behavior occurs, patients should be fully evaluated.
• Antipsychotics are best limited to patients who have psychotic symptoms or behave aggressively, who are unresponsive to nondrug therapies, and whose behavior poses a threat to themselves or others.
• All antipsychotics have adverse effects and should be used only when necessary; their use should be closely monitored. Although the 2nd-generation antipsychotics aripiprazole, olanzapine, quetiapine, and risperidone have fewer adverse effects than 1st-generation antipsychotics, they increase overall mortality risk in elderly patients with dementia-related psychosis; these drugs should be used with caution. Cholinesterase inhibitors and memantine are the next best choices, but the effect of these drugs is small.
• In patients who have dementia with Lewy bodies, adverse effects of antipsychotic drugs tend to be common and severe.
• Depression is common among patients with dementia and may affect behavior.

Behavioral and psychologic symptoms of dementia (BPSD) are common among patients with dementia. Elderly patients admitted to hospitals may have or develop BPSD, and BPSD are the primary reason for up to 50% of nursing home admissions. These symptoms can contribute to or provoke mistreatment by caregivers and contribute to depression and burnout in caregivers. As a result, BPSD are some of the most costly disorders affecting the elderly. Nevertheless, little research about them has been done. The epidemiology and natural history of BPSD have not been well characterized, and optimal treatment has not been determined.

Tolerability (what can be tolerated by people with whom a patient lives) greatly influences whether a patient with BPSD requires medical attention, and the relative importance of individual symptoms depends largely on the patient's living arrangements. For example, wandering at home or sleeping during the day and staying awake all night may be considered eccentric but not intolerable when a person lives alone, but these behaviors may be problematic when a person lives with other people. In a family residence, such behavior may disrupt normal activities. In a nursing home or hospital, staff members may consider such behavior intolerable because it disturbs other patients or interferes with the operation of the institution.

Different people who interact with the patient may have different tolerance levels. For example, one attendant in a nursing home may readily tolerate frequent, repetitive questioning, but another attendant may become frustrated and annoyed by the constant interruptions. BPSD in institutionalized patients may be better tolerated during the day, when many staff members are working and the activity level is high, rather than during the night, when fewer staff members are working and the activity level is low.

Environmental factors, particularly those related to safety, also affect tolerability. For example, wandering may be better tolerated in a safe environment (eg, with locks and alarms on all doors and gates). Cooking may be considered an unsafe activity in some settings because it is hazardous to the patient and to others. However, the patient may be able to continue to cook if supervised. Many small homes for patients with dementia incorporate supervision into their approach; the goal is to enable patients to continue as many of their typical daily activities as possible.

Time of day seems to be an independent factor in increasing BPSD. Sundowning (exacerbation of disruptive behaviors at sundown or early evening, when agitation is pronounced) often becomes prominent in patients with moderate to severe dementia. In nursing homes, 12 to 14% of patients with dementia have more behavior disturbances during the evening than during the day.

Risk Factors

At least 4 functional changes related to dementia may result in BPSD.

• Patients with dementia lose adult inhibition and forget appropriate public or private behavior. Thus, they may yell in an inappropriate environment (eg, in a restaurant) or undress in public.
• Patients may misunderstand visual and auditory cues. Thus, they may lash out at a nurse whom they perceive as a threat.
• Patients have impaired short-term memory. Thus, they cannot remember directions, may repeat questions and conversations, demand constant attention, or ask for things (eg, meals) that they have already received.
• Patients may have problems expressing their needs clearly or at all. Thus, they may yell when in pain or short of breath. They may wander when lonely, confused, or frightened, or they may urinate in public when their bladder feels full.

Institutional living may contribute to BPSD because routines are developed for the convenience of the staff. Mealtimes, bedtimes, and toileting times are not individualized; there are few opportunities for intimacy. Often, patients with dementia cannot learn new rules or routines and thus adapt poorly to this regimentation.

Other disorders can exacerbate BPSD. Pain, shortness of breath, a UTI, urinary retention, constipation, oral or dental pain, or physical abuse may change the pattern or intensity of BPSD. Delirium (acute confusion) superimposed on chronic dementia can also exacerbate BPSD; delirium may be the first indication of a new pathophysiologic process.

Classification

BPSD are often collectively referred to as agitation. However, using this term, which has so many meanings, does not help in planning a management strategy. Characterizing and classifying the behavior are more useful (see Table 41-1). The Cohen-Mansfield Agitation Inventory is commonly used; it groups behaviors into 4 categories:

• Physically aggressive (eg, hitting, pushing, kicking, biting, scratching, grabbing people or things)
• Physically nonagressive (eg, handling things inappropriately, hiding things, dressing or undressing inappropriately, pacing, repeating mannerisms or sentences, acting restless, trying to go elsewhere)
• Verbally aggressive (eg, cursing, making strange noises, screaming, having temper outbursts)
• Verbally nonaggressive (eg, complaining, whining, constantly requesting attention, not liking anything, interrupting with relevant or irrelevant remarks, being negative or bossy)

Specific behaviors and precipitating events (eg, feeding, toileting, drug administration, visits) should be recorded along with the time the behavior starts and ends and the type of, time of, and response to treatment. Keeping such a record makes planning a management strategy easier and helps identify changes in pattern or intensity of a behavior. If a change is observed, a physical examination should be done to exclude physical disorders and physical abuse. Sometimes a change in a patient's behavior reflects a rotation or substitution of caregivers (eg, nurse, attendant, family member) rather than a change in the patient.

Identifying predominantly psychologic symptoms (eg, depression, anxiety, delusions, hallucinations) is essential because specific treatments may be available for these symptoms. Depression can be difficult to identify in patients with dementia. It may first manifest as an abrupt change in cognition, decreased appetite, deterioration in mood, a change in sleep pattern (often hypersomnolence), withdrawal, decreased activity level, crying spells, talk of death and dying, sudden development of irritability, psychosis, or other sudden changes in behavior. Often, depression is suspected first by family members.

Signs of psychosis occur in about 10% of patients with dementia; this percentage may be slightly higher among nursing home residents. Several types of delusions (persistent false beliefs that are not based on reality) occur in dementia. For example, patients with dementia often suffer from paranoia about theft, which may be a reflection of their memory impairment. Patients' other common delusions are that their house is not their home, that their spouse has been replaced, or that they will be abandoned (eg, by an unfaithful spouse). Patients with paranoia may appear terrified or quietly withdrawn; when questioned, they may claim that others are trying to harm them, often in a specific way (eg, by poisoning).

Hallucinations, usually consisting of seeing or, less commonly, of hearing something that has no external source, may occur in patients with dementia. Hallucinations should be distinguished from illusions, which involve misinterpreting external sensory stimuli (eg, cellular phones, pagers). Visual hallucinations are a key diagnostic feature of dementia with Lewy bodies and thus can have important treatment implications. Patients with this dementia are very sensitive to drugs that block dopamine receptors (eg, antipsychotics). Using antipsychotics to treat this dementia increases risk of extrapyramidal symptoms and the potentially fatal neuroleptic malignant syndrome and has been associated with increased morbidity and mortality rates.

Treatment

Management of BPSD is one of the most controversial areas of geriatric medicine. Few controlled studies have examined the effectiveness of purported treatments, and very few well-designed studies have compared types of drugs.

Nondrug therapy: A consensus panel on the treatment of elderly patients with BPSD (especially those with psychotic symptoms) recommends including environmental intervention and caregiver education. However, because of traditional training, lack of resources to teach caregivers, and reimbursement policies, physicians usually prescribe drugs rather than attempt nondrug therapies.

Environmental intervention is often the most successful, least expensive, and safest treatment. In institutions, the environment should be safe and flexible to accommodate behaviors that are not dangerous. Ideally, the physical environment should be designed to provide ample, unobstructed room for patients who wander. For example, a floor pattern may have a pathway that goes along the perimeter of the building and circles the patients' rooms and administrative offices; on it, patients can walk without encountering barriers such as walls, doors, or clusters of other residents or staff members. Doors should be equipped with locks or alarms. Signs can help patients find their way.

Sleeping hours should be flexible to accommodate patients with insomnia. Adjusting light levels to reflect a typical day-night pattern can help provide cues for patients to sleep at predictable times. Reorganization of beds (separating noisy from quiet patients) can help reduce intolerable noise levels. Couples should room together (if they want to) in separate beds, and sexual activity should be allowed and facilitated as long as other residents and staff members are protected from unwanted encounters.

Providing cues about time and place and explaining what is going to happen beforehand (especially before providing care) can often forestall violent outbursts. Frequent brief visits by staff members can prevent yelling. Physical activity should be encouraged because it often helps patients sleep without using drugs and may reduce the incidence of wandering, noisiness, hitting, and throwing. Similar interventions to improve the physical and interpersonal environment can be used at home.

If an institution cannot provide an appropriate environment for a particular patient, the patient should be moved to another institution. For example, if a patient who wanders resides in a nursing home that cannot provide doors with locks or alarms, transfer to another home may be preferable to treatment with drugs that do not improve and often aggravate this behavior.

Various other nondrug therapies (eg, music therapy, aromatherapy, pet therapy, reminiscence therapy, multisensory stimulation) have been studied. Evidence supporting the use of some of these therapies to treat BPSD is emerging but remains inconclusive.

Nurses and social workers are in the best position to evaluate and implement environmental interventions. With physician support, they can help nursing home administrators design an institutional environment that is appropriate for patients with BPSD.

Drugs: Drugs given primarily to improve cognition may have a positive effect on BPSD; examples are cholinesterase inhibitors in dementia with Lewy bodies, Alzheimer's disease, and possibly vascular dementia and memantine in Alzheimer's disease and possibly vascular dementia. However, in such cases, BPSD are not considered the main reason for use of these drugs. Drugs should be used primarily to treat BPSD only when nondrug treatments are ineffective and when drugs are absolutely necessary to maintain the safety of the patient and other people (eg, to control aggressive behavior). Drugs should be selected to target the most dangerous or intolerable behaviors. The need for continued use should be reassessed at least every 1 to 3 mo.

There is little evidence supporting the use of antidepressants, antipsychotics, mood stabilizers, cholinesterase inhibitors, or memantine to treat BPSD. Second-generation (atypical) antipsychotics (aripiprazole, olanzapine, quetiapine, and risperidone) may be modestly effective, but any benefit may be offset by increased risk of stroke and all-cause mortality. Recommendations for their use vary greatly, and these drugs should be used with caution. Also, all antipsychotics can cause extrapyramidal symptoms, tardive dyskinesia, and tardive dystonia. These adverse effects are particularly common and severe in patients who have dementia with Lewy bodies. Neurologic adverse effects may occur less frequently with 2nd-generation antipsychotics.

When used in elderly patients, antipsychotics should be started at very low doses (eg, risperidone 0.25 mg once/day or bid, olanzapine 5 mg once/day). The target dose is 0.5 to 0.75 mg once/day or bid for risperidone and 5 to 10 mg once/day for olanzapine. Higher doses increase risk of adverse effects without evidence of increased efficacy. Risks and benefits should be discussed with family members before antipsychotics are prescribed.

Despite concerns about using antipsychotics, the frustration of caring for patients with BPSD often prompts physicians to prescribe these drugs. Many physicians prescribe sedatives (eg, short-acting benzodiazepines) when drugs are needed (ie, when environmental interventions do not make behavior tolerable). The only controlled study of a benzodiazepine compared lorazepam 1 mg IM with olanzapine 2.5 mg or 5 mg IM and placebo. Olanzapine and lorazepam were superior to placebo at 2 h, but only olanzapine was superior at 24 h.

Depression, which affects 20% of patients with Alzheimer's disease, should be treated. Antidepressants that do not have anticholinergic properties (usually SSRIs) are preferred.

Caregiver issues: Caregiver education is essential for family members and professional caregivers (eg, staff members in nursing homes, home health care workers) who care for patients with BPSD. Specific questions should be covered (see Table 41-2). Nurses and social workers can teach family members and other caregivers how to best meet the patient's needs; this teaching should be ongoing. The 36-Hour Day, a guide to caring for patients with dementia, provides invaluable information, including how to deal with daily care, get outside help, and handle financial issues.

Caregivers should be taught how to manage stress, which may be considerable and often requires intervention. Stress may be caused by fear of inadequately protecting the patient, frustration from having to repeat directions and restrictions, exhaustion from the intense supervision required for the patient, anger from watching an adult behave like an undisciplined child, and resentment from having to do so much to care for someone. Stress may cause a caregiver, regardless of setting, to punish or abuse the patient. Physicians and social workers should monitor caregivers for signs of stress. Stressed caregivers should be referred to available support services, such as social workers, caregiver support groups, and home health aides, and should be told how to obtain respite care if such care is available.

Caregivers should also be monitored for depression, which occurs in nearly ½ of people caring for a family member with dementia. Depression in caregivers should be treated promptly.

This topic was last updated February 2006.