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

Pharmacological Management of BPSD in Hospital Settings

Non-pharmacological interventions should be implemented as first-line management for BPSD in hospital settings, with pharmacological interventions reserved for when non-pharmacological approaches have failed or when there is significant distress or safety risk to the patient or others. 1

Assessment Before Pharmacological Intervention

Before initiating any medication:

• Investigate underlying causes: pain, UTIs, constipation, medication side effects
• Document specific behaviors using ABC (antecedent-behavior-consequences) charting
• Assess severity, frequency, and impact on patient and others
• Rule out delirium as a cause of behavioral changes

Pharmacological Management Algorithm

1. For Psychosis/Severe Agitation (delusions, hallucinations, combativeness)

Atypical Antipsychotics:

• Risperidone: Start 0.25 mg daily at bedtime; maximum 2-3 mg/day in divided doses 2
• Olanzapine: Start 2.5 mg daily at bedtime; maximum 10 mg/day in divided doses 2
• Quetiapine: Start 12.5 mg twice daily; maximum 200 mg twice daily 2

Important Warnings:

• FDA black box warning: Increased mortality risk in elderly patients with dementia-related psychosis 3, 4
• Short-term use only (typically 1-2 weeks in acute hospital setting)
• Monitor for extrapyramidal symptoms, sedation, orthostatic hypotension
• Avoid typical antipsychotics if possible due to higher risk of severe side effects 2

2. For Anxiety/Agitation Without Psychosis

Mood-Stabilizing Agents:

• Trazodone: Start 25 mg daily; maximum 200-400 mg/day in divided doses 2
  • Use with caution in patients with cardiac issues
• Divalproex sodium: Start 125 mg twice daily; titrate to therapeutic blood level (40-90 mcg/mL) 2
  • Monitor liver enzymes and platelets

3. For Depression with Agitation

SSRIs:

• Consider in patients with moderate to severe depression 2
• Start with low doses and increase slowly
• Allow 3-4 weeks for full effect assessment

4. For Severe Acute Agitation Requiring Immediate Intervention

Benzodiazepines:

• Use only for short-term management of severe agitation
• Prefer agents with shorter half-lives (lorazepam, oxazepam)
• Caution: can cause paradoxical agitation in approximately 10% of elderly patients 2
• Risk of falls, cognitive impairment, and dependency

Important Considerations

1. Start low, go slow: Begin with lowest possible doses and titrate gradually 1

2. Regular monitoring:

   • Assess effectiveness daily
   • Monitor for adverse effects
   • Document response to medications

3. Time-limited use:

   • Plan for medication review and potential discontinuation
   • Avoid long-term use of antipsychotics for BPSD

4. Avoid certain medications:

   • Thioridazine, chlorpromazine, or trazodone should not be used as first-line treatment 2
   • Haloperidol should not be used as first-line management 2

5. Medication combinations:

   • Avoid polypharmacy when possible
   • If using multiple agents, monitor closely for drug interactions

Common Pitfalls to Avoid

1. Overreliance on antipsychotics: Despite their effectiveness for severe symptoms, they carry significant risks and should be used at the lowest effective dose for the shortest duration 2

2. Inadequate trial of non-pharmacological interventions: Always implement environmental modifications, redirection techniques, and structured activities before resorting to medications 1

3. Failure to discontinue: Many medications can be tapered and discontinued once the acute crisis has resolved

4. Overlooking underlying causes: Unaddressed pain, infection, or environmental triggers often contribute to BPSD and should be treated before or alongside symptom management

5. Using medications as chemical restraints: This practice is inappropriate and potentially harmful; medications should address specific symptoms, not simply sedate the patient

In the hospital setting, the goal of pharmacological management should be to address specific target symptoms while minimizing risks, with a clear plan for medication review and potential discontinuation upon improvement or discharge.