What is the recommended treatment for Behavioral and Psychological Symptoms of Dementia (BPSD)?

Management of Behavioral and Psychological Symptoms of Dementia (BPSD)

High-quality, person-centered care, including psychosocial interventions, is the first line of treatment for BPSD, with medications used only as a carefully monitored, short-term, last resort in specific cases when symptoms are severe, dangerous, or causing significant distress. 1

Assessment of BPSD

• Thoroughly assess the type, frequency, severity, pattern, and timing of symptoms to guide appropriate intervention 1, 2
• Evaluate for potentially modifiable contributors to symptoms, particularly pain, which is often undertreated and can manifest as agitation in dementia patients 1, 2
• Use quantitative measures to assess the severity of agitation and response to treatment 1, 2
• Consider the dementia subtype, as this may influence treatment choices 1

Non-pharmacological Interventions (First-Line)

Environmental and Behavioral Approaches

• Provide a predictable routine (exercise, meals, and bedtime should be routine and punctual) 1
• Allow patients to dress in their own clothing and keep personal possessions 1
• Explain all procedures and activities in simple language before performing them 1
• Simplify tasks by breaking complex tasks into steps with instructions for each step 1
• Use distraction and redirection of activities to divert the patient from problematic situations 1

Caregiver-Focused Strategies

• Train caregivers in the "three R's" approach: repeat instructions as needed, reassure the patient, and redirect attention to another activity 1
• Educate caregivers that behaviors are not intentional and suggest ways to improve communication (calmer tones, simpler single-step commands, light touch to reassure) 1
• Help caregivers establish a "new normal" routine that promotes patient safety and well-being 1
• Register patients at risk for wandering in the Alzheimer's Association Safe Return Program 1

Environmental Modifications

• Ensure a safe environment (no sharp-edged furniture, slippery floors, throw rugs, or obtrusive electric cords) 1
• Install safety locks on doors and gates, and grab bars by toilets and in showers 1
• Use calendars, clocks, labels, and newspapers for orientation to time 1
• Use color-coded or graphic labels as cues for orientation in the home environment 1
• Reduce excess stimulation, glare from windows and mirrors, noise from television, and household clutter 1

Pharmacological Management

When to Consider Medication

• Antipsychotic medications should only be used when symptoms are severe, dangerous, or causing significant distress to the patient 1, 2
• Medication should be considered only after significant efforts to implement non-pharmacological interventions have failed 1
• Exceptions where earlier medication use may be considered include: major depression with or without suicidal ideation, psychosis causing harm or with great potential for harm, and aggression causing risk to self or others 1

Medication Selection

• For depression in patients with dementia, selective serotonin reuptake inhibitors (SSRIs) such as citalopram and sertraline are preferred due to minimal anticholinergic side effects 1
• For severe agitation or psychosis, low-dose atypical antipsychotics may be considered with careful risk assessment 2
• Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) may help improve behavioral symptoms in some patients 1, 3

Medication Administration and Monitoring

• Start at the lowest possible dose and titrate slowly to the minimum effective dose 2
• Discuss risks and benefits with the patient (if clinically feasible) and surrogate decision-makers before initiating treatment 1
• Be aware of increased risks of serious adverse events including falls, stroke, and death with antipsychotic use 1
• Monitor closely for adverse effects, particularly extrapyramidal symptoms with antipsychotics 4
• If no clinically significant response occurs after a 4-week trial of an adequate dose, taper and withdraw the medication 2
• Periodically reassess the need for continued medication in patients who respond positively 2

Important Cautions

• Antipsychotic medications have modest efficacy at best for BPSD, with small effect sizes 2
• Thioridazine or chlorpromazine should not be used for the treatment of BPSD 1
• Haloperidol and atypical antipsychotics should not be used as first-line management 1
• There is no FDA approval for the use of antipsychotics in the treatment of BPSD 1
• Regular follow-up is essential to monitor for adverse effects and to evaluate the continued need for medication 1, 2
• Consider a trial of dose reduction or discontinuation of psychotropic medications periodically, as NPS change and fluctuate over the course of dementia 1