Helen F. K. CHIU*, S. W. LI

· Forum ·

Management of Behavioral and Psychological Symptoms of Dementia (BPSD)—no easy solution

Helen F. K. CHIU1*, S. W. LI2

Management of the behavioral and psychological symptoms of dementia (BPSD) is a hot topic because these commonly seen symptoms in persons with dementia are quite difficult to manage. As highlighted in the comments by Xiao[1], the administration of antipsychotics is controversial because the use of antipsychotic medications in persons with dementia is associated with increased mortality, increased risk of stroke and worsened cognitive function[2,3]. Xiao recommends that more long-term follow-up studies on the management of the BPSD be conducted to give clinicians better guidance on the treatment of this complex condition. This recommendation is particularly pertinent for Chinese populations. Two studies from Hong Kong showed that patients with the BPSD who were treated with antipsychotic medications did not have an increased risk of cerebrovascular accidents[4]or mortality[5]. Clearly, more studies should be conducted in populations of different ethnicity to con firm or disprove the presumed risks of antipsychotic medications in patients with dementia.

While the evidence base for antipsychotic medications is strongest for the treatment of aggression and agitation in people with the BPSD,other psychotropic drugs may also be beneficial.Cholinesterase inhibitors appear to be more useful for the treatment of depression, apathy, aberrant motor behavior and anxiety, while memantine may be useful for irritability, agitation, aggression and psychosis[2,6].There is also preliminary evidence that citalopram and carbamazepine are potentially useful for treating agitation and aggression[6]. However, most psychotropic drugs have significant side effects in the elderly and the clinical benefits are at most modest so all such medications must be used cautiously in patients with the BPSD. This is highlighted by a recent study which showed that use of a conventional antipsychotic medication, an antidepressant or a benzodiazepine inresidents of nursing homes was associated with risks of death or hospitalization comparable to or higher than the risks of using an atypical antipsychotic[7]. Moreover,the increased risk associated with these medications were similar in patients with and without dementia.

Currently many treatment guidelines and experts in the field recommend initially trying non-pharmacological interventions followed by psychotropic drugs for patients who do not respond to these initial measures.Antipsychotic medications should only be used if the symptoms are very severe and potentially dangerous to the patient or other people. In addition, antipsychotic medications should be used at a low dose and only for a short period of time.

These recommendations are reasonable in most situations, but there are some caveats. First, there is growing evidence that a variety of non-pharmacological interventions including behavioral modification,psychoeducation for careers and environmental adaptations are useful in the management of BPSD[8],but the evidence base supporting the benefit of these interventions remains limited because most of the available studies have small samples and methodological problems. Second, these promising psychosocial interventions for the BPSD require trained staff and resources[9]that may not be available in many settings. Multidisciplinary professional input is essential in providing environmental modifications,reminiscence therapy, cognitive interventions,aromatherapy, physical activity, and so forth. This is a particularly relevant issue in China—where providing psychosocial interventions for patients with dementia is a new field—because there are few, if any, trained staff in China who can provide these interventions.There are also resource implications as the manpower required to deliver quality psychosocial interventions is considerable. Thirdly, clinicians must realize that although there are side effects and risks associated with antipsychotic treatment, there are also risks in withholding antipsychotic medications for certain patients.In situations where the BPSD do not respond to nonpharmacological measures and where the patient is greatly distressed by psychotic symptoms or agitation,or the symptoms pose a danger to the patient, the carers or others, antipsychotic medications could be considered after due discussion with the patient and/or family members. The authors of a recent editorial highlight the dilemma:they assert that while it is unethical to assume all people with BPSD need treatment with antipsychotic medications, it is equally unethical to assume that antipsychotic medications should never be used[10].

There is no easy solution to the management of BPSD. An individualized approach is essential. Clinicians should weigh the risks and benefits of various treatment options in each patient cautiously. With the exponential rise in the number of people with dementia in China, one of the key challenges in health care over the coming years will be providing care for persons with dementia.

1. Xiao S. Treating the behavioral and psychological symptoms of senile dementia with antipsychotic drugs. Shanghai Arch Psychiatry, 2011, 23(6):376-378.

2. Gauthier S, Cummings J, Ballard C,Brodaty H,Grossberg G,Robert P, et al. Management of behavioral problems in Alzheimer’s disease. Int Psychogeriatr, 2010, 22(3):346-372.

3. Vigen CL, Mack WJ, Keefe RS, Sano M, Sultzer DL, Stroup TS, et al. Cognitive effects of atypical antipsychotic medications in patients with Alzheimer’s disease:outcomes from CATIE-AD. Am J Psychiatry, 2011, 168(8):831-839.

4. Chan MC, Chong CS, Wu AY, Wong KC, Dunn EL, Tang OW, et al.Antipsychotics and risk of cerebrovascular events in treatment of behavioural and psychological symptoms of dementia in Hong Kong:a hospital-based, retrospective, cohort study. Int J Geriatr Psychiatry, 2010, 25(4):362-370.

5. Chan TC, Luk JK, Shea YF,Lau KH,Chan FH,Yu GK, et al. Continuous use of antipsychotics and its association with mortality and hospitalization in institutionalized Chinese older adults:an 18-month prospective cohort study. Int Psychogeriatr, 2011,23(10):1640-1648.

6. Ballard C, Corbett A, Chitramohan R, Aarsland D. Management of agitation and aggression associated with Alzheimer’s disease:controversies and possible solutions. Curr Opin Psychiatry, 2009, 22(6):532-540.

7. Huybrechts KF, Rothman KJ. Silliman RA, Brookhart MA,Schneeweiss S. Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults admitted to nursing homes. CMAJ, 2011,183(7):E411-419.

8. Livingstone G, Johnston K, Katona C, Paton J, Lyketsos CG.Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry, 2005, 162(11):1996-2021.

9. Pollock BG, Mulsant BH. Between Scylla and Charybdis:antipsychotic and other psychotropic medications in older nursing home residents. CMAJ, 2011:183(7):778-779.

10. Treloar A, Crugel M, Prasanna A, Solomons L, Fox C, Paton C, et al. Ethical dilemmas: should antipsychotics ever be prescribed for people with dementia? Br J Psychiatry, 2010, 197(2):88-90.

1Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, China2Castle Peak Hospital, Hong Kong, China

* Correspondence: helenchiu@cuhk.edu.hk