Neuropsychiatric Symptoms

of Dementia

Dr. Dallas Seitz MD FRCPCAssistant Professor, Department of Psychiatry

Queen’s University

Objectives

1.) Understand the prevalence and importance of neuropsychiatric symptoms (NPS) of dementia2.) Review the biological and psychosocial factors associated with the development of NPS3.) Review the evidence for pharmacological and non-pharmacological treatments for NPS

Neuropsychiatric Symptoms• Non-cognitive symptoms associated with

dementia• Also known as Behavioral and Psychological

Symptoms of Dementia (BPSD)– International Psychogeriatrics Association 1996

“Signs and symptoms of disturbed perception, thought content, mood, or behavior that frequently occur in patients with dementia”1

1. Finkel, Int Psychogeriatr, 1996; 8(suppl 3):497-500

What are Neuropsychiatric Symptoms?

• Agitation2:– Restlessness– Requests for help or

repetitive questioning– Screaming or

vocalizations– Hitting, pushing, kicking– Sexually disinhibited

behavior

Delusions1

Hallucinations Anxiety Elevated mood Apathy Depression Irritability Sleep Changes

1. Cummings, Neurology, 19942. Cohen-Mansfield, J Geronotol, 1989

Clusters of Neuropsychiatric Symptoms

• Cohen-Mansfield Agitation Inventory (CMAI)1:

– Verbal agitation (yelling, repetitive vocalizations)– Non-aggressive physical agitation (restlessness, pacing)– Aggressive physical agitation

• Neuropsychiatric Inventory (NPI)2:

– Psychotic symptoms (delusions/hallucinations)– Mood/Apathy (depression/apathy/eating/sleep)– Hyperactivity (agitation/irritability/euphoria/disinhibition)

1. Cohen-Mansfield, J Gerontol, 19892. Aalten, Dement Geriatr Cogn Disord, 2003

Prevalence of NPS

Any NPI

Delusions

Hallucin

ations

Agitation/A

ggressi

on

Depression

Anxiety

Euphoria

Apathy

Disinhibition

Irrita

bility

Motor Behavior

Sleep

Eating

0

10

20

30

40

50

60

70

80

Any Symptom

Severe

Prev

alen

ce in

Pas

t 30

Days

Lyketsos, JAMA, 2002

Prevalence of NPS in Long-Term Care

• 60% of individuals LTC settings have dementia1

• Overall prevalence of NPS:– Median prevalence of any

NPS: 78%

1. Seitz, Int Psychogeriatr, 20102. Zuidema, J Geriatr Psych Neurol, 2007

• Prevalence of NPS2: – Psychosis 15 – 30%– Depression: 30 – 50%– Physical agitation: 30%– Aggression: 10 – 20%

Persistence of NPS

• Neuropsychiatric symptoms are often chronic1,2

– More likely to persist: delusions, depression, aberrant motor behavior

– Less likely to persist: hallucinations, disinhibition

1. Steinberg, Int J Geriatr Psychiatry, 20042. Aalten, Int J Geriatr Psychiatry, 2005

Associations with Stage of Illness

Activity Affective Anxiety Aggression Hallucinations Delusions Sleep0

10

20

30

40

50

60

70

80

90

100

Mild

Moderate

Severe

Terminal

Chen, Am J Geriatr Psychiatry, 2000

Per

cent

age

of In

divi

dual

s w

ith S

ympt

oms

Impact of Neuropsychiatric Symptoms

• Increased patient and caregiver distress1

• Increased risk for institutionalization• More rapid functional decline• Increased risk of mortality• Economic costs

1. Bannerjee, J Neurol Neurosurg Psychiatry, 2006

Causes of Neuropsychiatric Symptoms

• Biological• Psychological and social

Biological Correlates of NPS

• Neurotransmitter changes in acetylcholine, dopamine, noradrenergic, serotonin and GABA1

• Volume loss in certain brain regions associated with NPS2,3

• Decrease metabolism in frontal and cingulate cortex associated with psychotic symptoms4

1. Lanari, Mech Aging Develop, 20062. Rosen, Brain, 20053. Bruen, Brain, 20054. Sultzer, Am J Psychiatry, 2003

Psychological Theories of NPS

• Lowered Stress Threshold1

• Learning Theory2

• Unmet needs Tailored interventions3

– Verbal agitation – depression, loneliness– Physically non-aggressive agitation - stimulation– Physically aggressive agitation – avoiding

discomfort

1. Hall, Arch Psych Nurs, 19872. Cohen-Mansfield, Am J Geriatr Psych, 20013. Cohen-Mansfield, Am Care Quarterly, 2000

Understanding Neuropsychiatric Symptoms

• Kitwood’s Framework for Personhood in Dementia1

• SD = P + B + H + NI + SP– SD = manifestation of dementia– Personality – previous coping strategies– Biography – other challenges presented in life– Health – sensory impairment– Neuropathological impairment – location, type, severity– Social psychology – environmental effects on sense of

safety, value and personal being

1. Kitwood, Int J Geriatr Psychiatry, 1993

Management of Neuropsychiatric Symptoms

• Differential Diagnosis:– Delirium (medication-induced, other causes)– Depression– Pain or discomfort

1. Sink, JAMA, 2005

Assessment of NPS

• Assessment of behaviors– What are the risks associated with the behavior?

• To patient, caregivers/staff, other individuals– What is the behavior?

• E.g. using instrument such as CMAI or NPI– What type of dementia does the individual have?– What is the stage of dementia?– What are the goals of care?

Assessment

• ABC Approach– Antecedents to the behavior

(i.e. during care)• Behavioral charting using

Dementia Observation System DOS

– Behaviors (what was the behavior?)

– Consequences (what was the response to the behavior)

General Principles To Managing NPS

• Non-pharmacological treatments should be used first whenever available

• Even when NPS are caused by specific etiologies (pain, depression, psychosis) non-pharmacological interventions should be utilized with medications

• All non-pharmacological interventions work best when tailored to individual needs and background

• Family and caregivers are key collaborators and need to involved in treatment planning

IPA BPSD Guide, Module 5, 2010

Non-Pharmacological or Psychosocial Treatments

• Training caregivers or staff in behavioral management strategies and communication1,2

• Participation in pleasant events• Exercise• Music• Sensory stimulation (e.g. touch, Snoezelen,

aromatherapy)• Appear to be well-tolerated and not associated

with increased risk of mortality1. Cohen-Mansfield, Am J Geriatr Psychiatry, 20012. Livingston, Am J Psychiatry, 2005

Limitations of Psychosocial Treatments

• Modest effects of treatments– Effects size = 0.2 – 0.5 for many interventions

• Limited access to programs and human resources necessary for implement

• May required prolonged and sustained implementation for effects

• Effectiveness for aggression and psychosis may be limited– Agitation, depressive symptoms may be more likely to

respond

Resources

• Canadian Coalition for Seniors Mental Health– www.ccsmh.ca

• Murray Alzheimer Research and Education Program– www.marep.uwaterloo.ca

• Alzheimer’s Society – www.alzheimer.ca

Resources

• International Psychogeriatric Association BPSD Guides www.ipa-online.org

Links to Materials

• Webinars on Neuropsychiatric Symptoms– Assessment and Nonpharmacological

Management– Pharmacological Management

• Treatment Tool• CCSMH Pocket Card• www.dalllasseitz.webs.com

Acknowledgments

• Funding: – Canadian Institutes of

Health Research: KRS#103345 KAL#114493

– Clinician Scientist Salary Award, Queen’s University

Thank you

• Questions?