dr joy ratcliffe, consultant psychiatrist dr julie colville, clinical psychologist
Post on 19-Jan-2016
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Behavioural and Psychological Symptoms of Dementia
Non-pharmacological and pharmacological approaches
Dr Joy Ratcliffe, Consultant PsychiatristDr Julie Colville, Clinical PsychologistLorraine Smith, Advanced PractitionerManchester Mental Health and Social Care Trust
& CMFT
BPSD What is it?
Heterogeneous group non- cognitive behaviours Not a diagnostic category – but very important Think as a list of disturbed behaviours e.g.
Wandering Agitation Sexually disinhibited behaviours Aggression Paranoia/suspicion
Eliciting psychological/psychiatric problems e.g. depression, anxiety, delusional ideas/psychosis
All adds to risk
BPSD Behavioural and psychological symptoms of
dementia (BPSD) are common They can be problematic in clinical practice and can
form a significant part of the day-to-day work of primary care teams, later life psychiatry teams. CMHTs, inpatient and community settings.
We need to improve recognition and management of BPSD
Improved management can have a positive impact on the quality of life of our patients and carers both at home and in nursing/residential setting s
Positive management may also delay 24hr care
BPSD - Prevalence Vary widely Approx 2/3rds will experience BPSD at any one
time Approx 1/3 in the ‘clinically significant ‘range Can rise to 80% in care homes 20% for BPSD in Alzheimer’s disease BPSD tends to fluctuate with psycho-motor
agitation most common and persistent
BPSD - Impact BPSD rather than cognitive features are
the major causes of care giving burden Paranoia, aggression, disturbed sleep-
wake cycles important drivers for 24hr care
BPSD also associated with worse outcome and illness progression
Adds significantly to direct and indirect care costs
Multiple Factors that influence Behaviour
Non Pharmacological management of BPSD –
Must be ‘collaborative’ - Needs thorough Assessment - multiple factors Need nursing home staff to input into assessment
e.g. what do they know about their client? Need staff e.g. Nursing Home to play key part e.g.
ABCs - helps identify factors such as over/under stimulation, pain etc
Need staff to implement and monitor plans Care Staff do need training in dementia Need medical staff to ensure physical problems
optimally treated e.g. infection, pain
Non Pharmacological management of BPSD
Understanding client’s history, lifestyle, culture and preferences, including their likes, dislikes, hobbies and interests.
Providing opportunities for the person to have conversations with other people.
Ensuring the person has the chance to try new things or take part in activities they enjoy.
Environmental factors-signage, lighting, photographs.
Reminiscence therapy.
Shared Care
Shared care plans to enhance communication and collaboration.
Discuss shared care plan.
Principle of Behaviour Management - Observing and Describing
What is happening When does it happen How often does it happen Who is there when it’s happening What is communication like Why do you think it is happening Any other observations
Principles of Behaviour Management- Contingencies
What are we targeting: Frequency/ severity
High frequency/ low severity (lower consequences) Low frequency/high severity (higher consequences) High frequency/High severity (highest
consequences)
What are ‘contingencies? e.g. positive and negative reinforcement
Biological Management• Treat underlying cause• Psychotropics?• Severity• Risk• Distress• Medical comorbidity / other meds esp vascular
risks• Capacity• Views carers
Assessment Delirium (caution not to miss hypoactive)? PINCH ME (pain, infection, nutrition,
constipation, hydration, medications, environment)
PAIN (physical / pain, activity related, iatrogenic, noise / environment)
START LOW GO SLOW Review target symptoms and adverse effects How long to treat for Gradual withdrawal Licensed?
• Psychosis- risperidone (0.25-0.5mg bd), olanzapine (2.5-10mg), quetiapine (25-150mg) amisulpiride, aripiprazole, zuclopethixol
• Aggression- as above, trazadone, clomethiazole• Agitation / anxiety- as above, citalopram,
mirtazepine, memantine (AD), pregabalin• Depression- sertraline, citalopram, mirtazepine• Mania- valproate, lithium, antipsychotics• Apathy- sertraline, citalopram, cholinesterase
inhibitor (D, R, G)• Sleep- temazapam, zopiclone, melantonin
Lewy Body Dementia (LBD) CAUTION WITH ANTIPSYCHOTICS- quetiapine,
aripiprazole, clozapine 1st choice cholinesterase inhibitors Clonazepam for REM sleep disorders
Vascular Dementia (VD) Cholineterase inhibitors and memantine not
licensed but majority of cases mixed AD / VD
Cholinesterase Inhibitors Bradycardia Prolonged QTC LBBB Gastric bleeding risk (pmhx, aspirin, NSAIDS,
warfarin) COPD / asthma Epilepsy
Antipsychotics ECG, QTC, other changes Vascular risks Increase cognitive impairment
Antidepressants Sedation GI bleeding Na Falls (inc SSRIs) Citalopram –QTC, max dose 20mg
Anticonvulsants Limited evidence Adverse effects
Case Example Case example 75, female, vascular dementia, 24 hr care for 12
months Complaints from care staff
agitation ‘breathless’ hyperventilating, ‘attention seeking’ – calling every 5 mins Saying pain (but where?) toileting – incontinent faeces falls, (needing extra monitoring)
Case Example
PERSONAL – lived alone many years – over stimulated
- remove to quieter environment DEMENTIA – vascular with periods
disorientation unable to express distress (language)
- try and reorientation/reassurance spend time with
Case Example PHYSICAL – incontinence = ‘overflow’
compacted, meds 2 x laxatives and codeine (opposite actions?), pain (unable to express)
- Elimination of acute physical illness as triggers for BPSD. Reviewed with Advanced Practitioner - GP to check pain and review meds,
FALLS – interaction meds Trazadone and codeine , over –sedated
- meds review, Falls Team, Physio, frame
Case Example PSYCHOLOGICAL – fear of falling exacerbated
by previous falls, highly anxious (premorbidly – calling ambulance, GP, police etc)
Ongoing assessment by Psychology, anxiety still prominent
Linked to disorientation and/or premorbid anxiety Activity/distraction, optimal? Co pharmacological treatments – optimally
treated?
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