Transcript Neuropsychiatric Symptoms of Dementia: Towards Understanding

Neuropsychiatric Symptoms
of Dementia
Dr. Dallas Seitz MD FRCPC
Assistant Professor, Department of Psychiatry
Queen’s University
Objectives
1.) Understand the prevalence and importance
of neuropsychiatric symptoms (NPS) of
dementia
2.) Review the biological and psychosocial
factors associated with the development of NPS
3.) 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?
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Delusions1
Hallucinations
Anxiety
Elevated mood
Apathy
Depression
Irritability
Sleep Changes
1. Cummings, Neurology, 1994
2. Cohen-Mansfield, J Geronotol, 1989
• Agitation2:
– Restlessness
– Requests for help or
repetitive questioning
– Screaming or
vocalizations
– Hitting, pushing,
kicking
– Sexually disinhibited
behavior
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, 1989
2. Aalten, Dement Geriatr Cogn Disord, 2003
Prevalence of NPS
80
Prevalence in Past 30 Days
70
60
50
40
30
20
10
0
Lyketsos, JAMA, 2002
Any Symptom
Severe
Prevalence of NPS in Long-Term Care
• 60% of individuals LTC • Prevalence of NPS2:
– Psychosis 15 – 30%
settings have
– Depression: 30 – 50%
dementia1
– Physical agitation: 30%
• Overall prevalence of
– Aggression: 10 – 20%
NPS:
– Median prevalence of any
NPS: 78%
1. Seitz, Int Psychogeriatr, 2010
2. Zuidema, J Geriatr Psych Neurol, 2007
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, 2004
2. Aalten, Int J Geriatr Psychiatry, 2005
Associations with Stage of Illness
Percentage of Individuals with Symptoms
100
Mild
90
Moderate
80
Severe
70
Terminal
60
50
40
30
20
10
0
Activity
Affective
Chen, Am J Geriatr Psychiatry, 2000
Anxiety
Aggression Hallucinations
Delusions
Sleep
Impact of Neuropsychiatric Symptoms
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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.
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Lanari, Mech Aging Develop, 2006
Rosen, Brain, 2005
Bruen, Brain, 2005
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.
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3.
Hall, Arch Psych Nurs, 1987
Cohen-Mansfield, Am J Geriatr Psych, 2001
Cohen-Mansfield, Am Care Quarterly, 2000
Understanding Neuropsychiatric Symptoms
• Kitwood’s Framework for Personhood in
Dementia1
• SD = P + B + H + NI + SP
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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) nonpharmacological 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 mortality
1. Cohen-Mansfield, Am J Geriatr Psychiatry, 2001
2. 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?