From the Guidelines
Nonpharmacological interventions should be the first-line therapy for a patient with dementia and behavioral and psychological symptoms of dementia (BPSD).
Rationale
- The American Psychiatric Association practice guideline recommends reviewing the clinical response to nonpharmacological interventions prior to nonemergency use of an antipsychotic medication to treat agitation or psychosis in patients with dementia 1.
- This approach is supported by the fact that antipsychotic medications have small benefits and are associated with clinically significant adverse effects, including mortality 1.
- The guideline suggests that decisions about treatment should balance the potential benefits and harms of a particular intervention, taking into account the goals and preferences of the patient and their surrogate decision maker 1.
- Nonpharmacological interventions are preferred as the initial treatment approach, with antipsychotic medications considered only when necessary, such as in cases of dangerous agitation or psychosis 1.
From the Research
First-Line Therapy for Dementia and BPSD
The first-line therapy for a patient with dementia and behavioral and psychological symptoms of dementia (BPSD) involves non-pharmacological interventions.
- Non-pharmacological interventions should be tried prior to pharmacological interventions 2, 3, 4, 5
- These interventions can include personalized approaches such as physical exercise, music therapy, reminiscence therapy, and pet therapy 4, 5
- Collaborative care from care providers and family members is an important facilitating factor for non-pharmacological interventions 4
Pharmacological Interventions
Pharmacological interventions, such as antipsychotics and antidepressants, may be considered when non-pharmacological interventions are ineffective or when behaviors pose a significant safety risk.
- Antipsychotics should be prescribed only when behaviors pose a significant safety risk or if the person with dementia is very distressed 2, 3, 6
- Atypical antipsychotics are widely used as the first-line pharmacological approach to treat BPSD 3, 6
- Antidepressants, anxiolytics, and antiepileptics may also be used to treat specific symptoms of BPSD 3, 6
Symptom-Specific Interventions
Symptom-specific non-pharmacological interventions may be effective for managing individual symptoms of BPSD.
- Music therapy has been found to be effective for improving overall symptoms, depression, and anxiety 5
- Aromatherapy may be considered for agitation, while reminiscence therapy may be effective in managing overall symptoms and depression 5
- Exercise has relatively weak evidence supporting its effectiveness in addressing individual symptoms of BPSD 5