What is the recommended pharmacological management for Behavioral and Psychological Symptoms of Dementia (BPSD) in a hospital setting?

Pharmacological Management for BPSD in Hospital Settings

Non-pharmacological interventions should be implemented as first-line management for Behavioral and Psychological Symptoms of Dementia (BPSD) in hospital settings, with pharmacological interventions reserved for when non-pharmacological approaches have failed or when there is significant distress or safety risk. 1

Assessment and Identification of Underlying Causes

Before initiating any pharmacological treatment:

1. Screen for behavior changes through interviews with the patient, family members, and healthcare team 1
2. Investigate and treat potential underlying causes such as:
   • Pain or discomfort
   • Urinary tract infections
   • Constipation
   • Medication side effects
   • Environmental triggers 1

Non-Pharmacological Interventions (First-Line)

• Provide a predictable routine (meals, exercise, bedtime) 1
• Use orientation tools (calendars, clocks, labels) 1
• Simplify tasks and break complex activities into steps 1
• Use distraction and redirection techniques 1
• Ensure adequate lighting and reduce environmental stimuli 1
• Implement structured activities tailored to individual abilities and preferences 1
• Use the ABC (antecedent-behavior-consequences) charting approach 1

Pharmacological Management Algorithm

When non-pharmacological interventions fail and symptoms cause significant distress or safety risks:

Step 1: Target-Specific Medication Selection

1. For Depression/Anxiety:

   • Selective Serotonin Reuptake Inhibitors (SSRIs) such as citalopram or sertraline 1
   • Start with low doses and increase slowly
   • Monitor for side effects

2. For Psychosis/Severe Agitation:

   • Antipsychotics should be used with caution due to increased mortality risk 2, 3
   • If necessary, use lowest effective dose for shortest possible duration
   • Regular reassessment for continued need (every 4-6 weeks)
   • Consider discontinuation after behavioral symptoms have been controlled for 4-6 months 1

3. For Cognitive Symptoms with Behavioral Impact:

   • Cholinesterase inhibitors (donepezil, galantamine) may help reduce behavioral symptoms 2
   • Consider for mild to moderate dementia 1
   • Memantine for moderate to severe dementia 1

Step 2: Medication Initiation and Monitoring

• Start with low doses and titrate slowly ("start low, go slow") 1
• Monitor for side effects and effectiveness every 4 days 3
• Document target symptoms and response to treatment
• Reassess regularly for continued need and potential discontinuation

Evidence-Based Effectiveness

• Functional analysis-based interventions show moderate quality evidence for BPSD improvement (SMD -0.10) 2
• Music therapy shows low quality evidence for BPSD improvement (SMD -0.49) 2
• Analgesics show low quality evidence for BPSD improvement (SMD -0.24) 2
• Donepezil (SMD -0.15) and galantamine (SMD -0.15) show high quality evidence 2
• Antipsychotics show high quality evidence (SMD -0.13) but with significant risks 2, 3

Common Pitfalls and Cautions

• Antipsychotics significantly increase mortality risk (adjusted hazard ratio 5.78) 3
• Restraints were used in 22% of hospital admissions for patients with dementia 3
• Non-pharmacological interventions are often not systematically implemented or monitored 3
• Medications are frequently initiated in hospital settings without adequate assessment of underlying causes 3
• New antipsychotic prescriptions are common during hospitalization (70% of prescriptions) 3

Special Considerations in Hospital Settings

• Hospital environments can exacerbate BPSD due to unfamiliar surroundings 3
• Involve caregivers in care planning and implementation when possible 1
• Ensure consistent communication among healthcare team members about effective approaches
• Document both pharmacological and non-pharmacological interventions and their effectiveness
• Plan for medication review and potential discontinuation upon discharge

By following this structured approach to BPSD management in hospital settings, clinicians can minimize unnecessary medication use while effectively addressing distressing symptoms that impact patient care and safety.