What are the best practices for managing behavioral changes, such as swearing, anxiety, and hyper-vigilance, in a person with dementia?

From the Guidelines

Caring for a person with dementia who exhibits behaviors like swearing, anxiety, and hyper-vigilance requires a comprehensive approach combining non-pharmacological strategies as the first line of management, as recommended by the most recent guidelines 1.

Non-Pharmacological Strategies

Non-pharmacological strategies should be considered as the first-line management of an individual with vascular cognitive impairment (VCI) who is displaying behavior changes, including swearing, anxiety, and hyper-vigilance 1. These strategies include:

• Establishing a consistent daily routine to provide structure and reduce anxiety
• Creating a calm environment by minimizing noise, clutter, and overstimulation
• Identifying potential triggers such as pain, hunger, fatigue, or environmental factors when challenging behaviors occur
• Using validation therapy by acknowledging the person's feelings rather than contradicting them
• Techniques like distraction, reminiscence therapy, and gentle reassurance for anxiety and hyper-vigilance

Pharmacological Interventions

If pharmacological treatment is required, SSRIs such as sertraline or citalopram are considered first-line treatments for agitation in individuals with VCI, as they have been shown to significantly reduce overall neuropsychiatric symptoms, agitation, and depression 1. However, antipsychotics like risperidone or quetiapine may be prescribed for short periods in severe cases, although they carry risks including increased stroke risk.

Caregiver Support

Caregiver education and support are crucial, as is regular respite care to prevent burnout 1. Responding with patience and empathy is essential for effective management, as these behaviors often stem from the person's inability to communicate needs effectively or from fear and confusion due to cognitive decline.

Quality of Life

High-quality, person-centered care, including psychosocial interventions, is now recognized as the first line of prevention and treatment for behavioral and psychological symptoms of dementia (BPSD) and for supporting quality of life generally in people living with dementia (PLWD) 1.

From the Research

Caring for a Person with Dementia

• Caring for a person with dementia who is showing changing behavior such as swearing, anxiety, and hyper-vigilance requires a comprehensive approach 2, 3, 4, 5, 6
• The 5W method is a reliable and easy-to-use method in clinical practice to analyze shouting in dementia, which can be characterized as a "reflex", a "behavior", a "language", or an "aggression" 2
• Non-pharmacological interventions, such as patient-centered, environment-centered, and/or entourage-centered interventions, should be tried prior to pharmacological interventions 3, 6
• Training of formal caregivers is the most effective intervention for behavioral and psychological symptoms of dementia (BPSD) 3
• Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), have been investigated as an alternative psychopharmacological approach for managing BPSD, with some studies showing their efficacy in reducing symptoms of agitation 4, 5

Management of Behavioral and Psychological Symptoms of Dementia

• The management of BPSD is highly individualized and requires a thorough assessment of the person with dementia 3, 6
• Antipsychotics, such as aripiprazole and risperidone, have been shown to be effective in managing BPSD, but their use should be carefully considered due to potential side effects 3, 6
• Non-pharmacological interventions, such as behavioral and psychosocial interventions, have been shown to be effective in managing BPSD, but their implementation can be challenging in routine clinical practice 3, 4
• A systematic review and Bayesian network meta-analysis found that aripiprazole, escitalopram, donepezil, galantamine, memantine, and risperidone were superior to placebo in reducing BPSD symptoms 6

Pharmacological and Non-Pharmacological Interventions

• Pharmacological therapies, such as antipsychotics and antidepressants, can be effective in managing BPSD, but their use should be carefully considered due to potential side effects 3, 4, 5, 6
• Non-pharmacological interventions, such as patient-centered and environment-centered interventions, can be effective in managing BPSD and should be tried prior to pharmacological interventions 2, 3, 6
• A combination of pharmacological and non-pharmacological interventions may be the most effective approach in managing BPSD 3, 6