Exploration of non-pharmacological interventions in the management of behavioural and psychological symptoms of dementia

Introduction

Behavioural and psychological symptoms of dementia (BPSD) are considered integral parts of dementia. While pharmacotherapy is reserved for severe symptoms of BPSD, the associated adverse effects can be detrimental. Therefore, non-pharmacological intervention is recommended as the first line of treatment in the management of BPSD. This study aimed to explore the non-pharmacological approaches for the management of BPSD and the strategies and barriers to implementing them in secondary care facilities in Malaysia.

Methods

A qualitative study design was employed. Data were collected through observations and semi-structured interviews of 12 caregivers and 11 people with dementia (PWD) at seven secondary care facilities. Observations were written in the field notes, and interviews were audio-recorded and transcribed. All data were subjected to thematic analysis.

Results

Some personalised non-pharmacological interventions, such as physical exercise, music therapy, reminiscence therapy and pet therapy, were conducted in several nursing care centres. Collaborative care from the care providers and family members was found to be an important facilitating factor. The lack of family support led to care providers carrying additional workload beyond their job scope. Other barriers to non-pharmacological interventions were cultural and language differences between the care providers and PWD, inadequate staff numbers and training, and time constraints.

Conclusion

Although non-pharmacological approaches have been used to some extent in Malaysia, continuous education and training of healthcare providers and the family members of PWD is needed to overcome the challenges to their successful implementation.

Feasibility of the Cognitive Model for Behavioral Interventions in Older Adults with Behavioral and Psychological Symptoms of Dementia

Objectives: The purpose of this study was to develop an individually tailored, non-pharmacological treatment model, the Cognitive Model for Behavioral Interventions (CoMBI), for patients with Behavioral and Psychological Symptoms of Dementia (BPSD) and comorbid maladaptive personality traits (CMPT), and to explore its feasibility and effectiveness.Methods: CoMBI was developed and implemented in two geriatric psychiatric inpatient wards in the Netherlands. In this single-group pretest-posttest, feasibility study, 40 patients with BPSD and CMPT (M = 73.8, SD = 8.5) were treated with CoMBI. BPSD and CMPT were assessed using informant-based questionnaires. Wilcoxon signed-rank tests and effect size calculations were conducted to determine differences.Results: Wilcoxon signed-rank tests demonstrated a significant decrease of BPSD with medium (r = 0.45) to large (r = 0.56) effect sizes. CoMBI demonstrated high acceptability and compliance by health-care professionals and family members.Conclusions: CoMBI is a feasible treatment model for challenging behavior in patients with BPSD and CMPT. CoMBI is associated with a significant decrease in challenging behaviors regardless of etiology.Clinical implications: Focusing on personality and associated core needs could have a key role in the non-pharmacological treatment of the elderly with BPSD.

Complementary and alternative medicines for behavioral and psychological symptoms of dementia: A protocol of overview of systematic reviews

BACKGROUND

Dementia is causing a huge medical and socioeconomic burden. Along with strategies to delay cognitive decline in dementia, behavioral and psychological symptoms of dementia (BPSD) are major contributing factor to the burden of dementia, and have been an important clinical issue for successful management of dementia. However, pharmacological strategies such as antipsychotics raise concerns in terms of risk-to-benefit ratio in managing BPSD. Therefore, there is a need for an effective and safe alternative in BPSD management. From this point of view, various complementary and alternative medicines (CAMs) are attracting attention in BPSD management. Therefore, the overview will make it possible to evaluate the feasibility of using CAM as a potential treatment strategy for BPSD in terms of evidence-based medicine.

METHODS AND ANALYSIS

Comprehensive searching will be performed in 13 bibliographic databases from their inception dates to November 2021. Systematic reviews and/or meta-analyses that examined the effectiveness and safety of CAM modalities including herbal medicine, acupuncture, acupressure, aromatherapy, meditation, and relaxation on BPSD, will be included. The methodological quality of included reviews will be assessed by using the A MeaSurement Tool to Assess systematic Reviews-2. Two independent researchers will conduct study search, study selection, data extraction, and quality assessment processes.

RESULTS

The results of overview will be disseminated by the publication of a manuscript in a peer-reviewed journal or presentation at a relevant conference.

CONCLUSION

The findings of this overview will help to solve the major public health problem related to dementia, and will provide patients with dementia, their caregivers, clinicians, and health policy makers credible evidence in mitigating the burden of dementia.

ETHICS AND DISSEMINATION

As this protocol is for an overview of systematic reviews and meta-analyses, ethical approval is not required.

PROTOCOL REGISTRATION NUMBER

Open Science Framework registry (https://osf.io/g5f3m).

A Comparison of the Behavioral and Psychological Symptoms of Dementia (BPSD) in Early-Onset and Late-Onset Alzheimer's Disease - A Study from South East Asia (Kashmir, India)

BACKGROUND

A gradual increase in the longevity due to advancement of treatment modalities and a subsequent surge in elderly population in India have led to a growing curiosity in the geriatric age group with Alzheimer's disease (AD). Behavioral and psychological symptoms of dementia (BPSD) represent epiphenomena of AD. However, no comprehensive study has been carried out in South East Asia (Kashmir, India), to assess the behavioral and psychological symptoms in subtypes of AD.

OBJECTIVES

The purpose of this study was to assess BPSD in early-onset Alzheimer's disease (EOAD) and late-onset Alzheimer's disease (LOAD).

MATERIAL AND METHODS

The study was conducted in the Memory clinic of the postgraduate department of psychiatry, Government Medical College, Kashmir, India from January 2012 to March 2014. The diagnosis of AD patients was done according to NINCDS-ADRDA criteria. A total of 80 patients of AD were screened (40 with age of onset less than 65, and 40 with age of onset greater than 64). Neuropsychiatric inventory (NPI) was the instrument used for evaluating symptoms of BPSD. The data was analyzed using paired t-test.

RESULTS

The mean age of presentation of EOAD and LOAD was 63.10 years and 84.28 years, respectively, and the difference between the two was found to be statistically significant. The LOAD group had significantly higher symptom severity for delusions, agitation, anxiety, disinhibition, and nighttime behavioral disturbances (NBD) than the EOAD group (p ≤.0001).

CONCLUSION

The behavioral and psychological symptoms are significantly severe in late onset subtype compared to the early onset subtype of Alzheimer's disease in the Kashmiri (Indian) population.

Are there sensitive time periods for dementia caregivers? The occurrence of behavioral and psychological symptoms in the early stages of dementia

BACKGROUND

The behavioral and psychological symptoms associated with dementia (BPSD) can be burdensome to informal/family caregivers, negatively affecting mental health and expediting the institutionalization of patients. Because the dementia patient-caregiver relationship extends over long periods of time, it is useful to examine how BPSD impact caregiver depressive symptoms at varied stages of illness. The goal of this study was to assess the association of BPSD that occur during early stage dementia with subsequent caregiver depressive symptoms.

METHODS

Patients were followed from the early stages of dementia every six months for up to 12 years or until death (n = 160). Caregiver symptoms were assessed on average 4.5 years following patient's early dementia behaviors. A generalized estimating equation (GEE) extension of the logistic regression model was used to determine the association between informal caregiver depressive symptoms and BPSD symptoms that occurred at the earliest stages dementia, including those persistent during the first year of dementia diagnosis.

RESULTS

BPSD were common in early dementia. None of the individual symptoms observed during the first year of early stage dementia significantly impacted subsequent caregiver depressive symptoms. Only patient agitation/aggression was associated with subsequent caregiver depressive symptoms (OR = 1.76; 95% CI = 1.04-2.97) after controlling for concurrent BPSD, although not in fully adjusted models.

CONCLUSIONS

Persistent agitation/aggression early in dementia diagnosis may be associated with subsequent depressive symptoms in caregivers. Future longitudinal analyses of the dementia caregiving relationship should continue to examine the negative impact of persistent agitation/aggression in the diagnosis of early stage dementia on caregivers.

Effects of animal-assisted therapy on behavioral and/or psychological symptoms in dementia: a case report

BACKGROUND

Recently, interest in nonpharmaceutical interventions in dementia care has increased. Animal-assisted therapy has been shown to be one promising intervention but more knowledge is needed. The present article reports on a pilot study involving an 84-year-old woman with vascular dementia who was systematically trained with a therapy dog team for 8 weeks.

METHODS

A quasi-experimental longitudinal interventional design with pre-post measures was used. Data were collected on 3 occasions. Descriptive statistics were used for data analysis.

RESULTS

Some effects on the woman's ability to walk and move were identified. In addition, some effects in the woman's cognitive state were observed.

CONCLUSIONS

Physical, psychological, and/or social training with certified therapy dog teams can have effects on behavioral and psychological symptoms in people living with dementia. Further research is needed.

The problem with "problem behaviors": a systematic review of the association between individual patient behavioral and psychological symptoms and caregiver depression and burden within the dementia patient-caregiver dyad

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSDs) are routinely cited as important predictors of caregiver burden and depression. Although BPSDs include a wide variety of patient behaviors, they are routinely grouped together as one construct to differentiate them from cognitive symptoms of dementia. Determining the specific BPSDs that result in increased depression and burden for caregivers may elucidate the stress process for caregivers and facilitate the development of effective interventions for caregivers.

METHODS

We conducted a systematic review of English-language articles published from 1990 to 2010 to determine whether there are known symptoms or symptom clusters which exert undue negative impact on caregiver depression and burden. Additionally, we review systems used for classifying BSPD symptom clusters and determine whether there have been any mechanisms studied by which individual BPSD symptoms negatively affect caregivers. Finally, we examine how the role of timing of symptoms has been examined within the literature.

RESULTS

Thirty-five original research articles examined the impact of an individual behavior symptom on caregiver burden or depression/depressive symptoms. The studies had no consistent system for categorizing symptoms. Although depression, aggression, and sleep disturbances were the most frequently identified patient symptoms to impact negatively on caregivers, a wide range of symptoms was associated with caregiver burden and depression.

CONCLUSIONS

The evidence is not conclusive as to whether some symptoms are more important than others. The studies reviewed were largely exploratory relative to the differential impact of individual BPSDs and did not focus on testing causal mechanisms by which specific symptoms exert more impact on caregiver mental health than others. Future research may benefit from the re-conceptualization of BPSDs from the perspective of their impact on the caregiver to examine hypothesis-driven differences among BPSD symptom clusters.

Sharing knowledge to advance healthcare policies in Europe for people living with dementia and their carers: the ALCOVE project

BACKGROUND

Alzheimer's disease and other related dementias are public health priorities in the European Union due to their prevalence, cost and profound impact on society. Because of these pressing implications, the European Union decided to create a Joint Action to share knowledge about dementia and health policy in order to preserve the health, quality of life, autonomy and dignity of people living with dementia and their carers in Europe.

METHODS

ALCOVE is a European Community-funded Joint Action coordinated by the HAS (French National Authority for Health) with a 24-month duration. The project's life cycle has been divided into the following four steps: (1) collection of existing information, (2) analysis of existing information and making comparisons across Member States, (3) identifying Evidence, Needs, and Priorities, (4) drafting recommendations and disseminating them.

RESULTS

19 countries are participating in the ALCOVE initiative. The project will publish its final findings in 2013. The project's objectives, participants, method, on-going procedures and work plans are already available on the ALCOVE website: http://www.alcove-project.eu/. Preliminary results show that recommendations will need to focus on clinical and epidemiological data collection, diagnostic system assessment, outstanding approaches for treating behavioural disorders, limiting antipsychotic use, and competence assessment in this vulnerable population.

CONCLUSIONS

The European Member States involved are mobilized to share best health policy practices in order to tackle the challenge of dementia's threat on European health and social systems and to improve the quality of life and care for individuals and their family carers.

A case of undue violent behavior associated with Alzheimer's disease

Although dementia is diagnosed by observing cognitive symptoms, noncognitive abnormalities are also highly prevalent. Although aggression is a common symptom, its presence is usually justifiable by a multitude of externally provoking factors. We present a case of Alzheimer's disease with marked unwarranted violent behavior.

An itemized approach to assessing behavioral and psychological symptoms in dementia

In an effort to obtain more detailed clinical information regarding behavioral and psychology symptoms in dementia, we submitted an existing, comprehensive measure of behavioral and psychology symptoms in dementia (Neuropsychiatric Inventory) to an alternate itemized scoring system. One hundred twenty-four caregivers of patients with dementia (mean Mini-Mental State Examination=22.6) rated the frequency of individual symptoms across all domains of the measure. Internal reliability and factor structures for all domains were analyzed to assess the stability of this scoring approach. Internal consistency alphas for each domain ranged from .57 to .91. Alpha reliability for the total inventory was .96. Results indicate an itemized approach to assessing behavioral and psychological symptoms in dementia among patients with mild-to-moderate dementia can be reliable, has the power to capture multiple features of neuropsychiatric symptoms, and can produce a rich neurobehavioral profile adding valuable information to the diagnosis and treatment of these patients.

Galantamine for the treatment of BPSD in Thai patients with possible Alzheimer's disease with or without cerebrovascular disease

OBJECTIVES

This study was to investigate an efficacy of galantamine in treatment of behavioral and psychological symptoms of dementia in Thai elderly who suffered from possible Alzheimer's disease (AD) with or without cerebrovascular disease and vascular dementia.

METHODS

A 6-month, multicenter, open-label, uncontrolled trial was undertaken in 75 patients. Eligible patients received an initial galantamine dose of 8 mg/dayand escalated over 5 to 8 weeks to maintenance doses of 16 or 24 mg/day. The behavioral response was assessed as an intention-to-treat analysis using the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD).

RESULTS

Galantamine improved behavioral and psychological symptoms of dementia (P < .05 vs baseline) over the 24 weeks of treatment. BEHAVE-AD score was significantly improved from baseline in paranoid and delusion ideation, diurnal rhythm disturbances, anxieties, and phobias.

CONCLUSIONS

Galantamine may be a well-tolerated and effective treatment option for improving psychotic, behavioral, and psychological symptoms in Thai elderly with possible AD with or without cerebrovascular disease and vascular dementia.

The progression of behavior in dementia: an in-office guide for clinicians

This article examines the progression of behavioral changes in 200 community living and long term care patients using the Kingston Standardized Behavioral Assessment, a measure of traditional neuropsychiatric behaviors (behavioral and psychological symptoms of dementia) and neuropsychological behaviors. A group of patients diagnosed with probable Alzheimer's disease or mixed dementia (Alzheimer's disease and vascular dementia), was assessed using the Kingston Standardized Behavioral Assessment, ranked by total Kingston Standardized Behavioral Assessment score and were divided into quartile-based groups. The scores revealed changes in behavior patterns across quartiles. Significant behavior change appeared even in quartile one. Lower scores were predominantly associated with neuropsychological behaviors; as scores increased, neuropsychiatric behaviors became equally common. An at-a-glance guide characterizing the patterns of increasing behavioral change is provided for clinicians. Behavioral changes appear both early and throughout dementia; the type and pattern of these emerging behaviors change as the disease progresses. Clinicians can use the typical patterns of behavioral change to identify behavioral impairment in individual patients and anticipate future changes and related care needs.

Cognitive and psychopathologic response to rivastigmine in dementia with Lewy bodies compared to Alzheimer's disease: a case control study

Cholinesterase inhibitors (ChEIs) are effective in improving cognition and behavior in patients affected by Alzheimer's disease (AD) as well as by Lewy bodies dementia (DLB). The authors compared the effect of rivastigmine in the treatment of cognitive impairment and behavioral and psychological symptoms of dementia (BPSD) in 30 AD and in 30 DLB patients. At baseline, DLB compared to AD patients showed a greater number of extrapyramidal symptoms (P < .005) and were similar regarding cognitive symptoms and BPSD. After treatment, both groups showed a comparable cognitive and psycho-behavioral improvement. A significant difference between AD and DLB patients was found for hallucinations (P < .002). Rivastigmine produces comparable cognitive benefits in patients with DLB and AD and also a significant improvement of behavioral disorders. These findings support the view that ChEIs should be considered a first-line treatment of the cognitive and psycho-behavioral symptoms of both AD and DLB.

The Kingston Standardized Behavioural Assessment

The Kingston Standardized Behavioural Assessment (KSBA), a behavioral screening tool that assesses the behavioral changes associated with dementia, particularly Alzheimer's disease (AD), is introduced. Designed to be user friendly for clinicians not trained in specialized behavioral assessment techniques, it addresses some of the problems of existing scales. A group of patients diagnosed with probable AD, vascular dementia, or mixed (AD and vascular) was assessed using the KSBA. A subgroup was also given the Neuropsychiatric Inventory (NPI). Behavioral profiles and scores were obtained for all subjects. Factor analysis revealed 2 factors described as neuropsychiatric and neuropsychological. The KSBA efficiently collects neuropsychological and neuropsychiatric behavioral symptoms of dementia, is easy to score and interpret, and yields a behavioral profile that helps identify target behaviors for intervention. It can be used to facilitate clinical decision making around level of care and can be easily incorporated into clinically based research.

Management of aggression, agitation, and psychosis in dementia: focus on atypical antipsychotics

The behavioral and psychological symptoms of dementia (BPSD), such as psychosis, agitation, or aggression have a considerable negative impact on the quality of life of both patients and their caregivers. Multiple studies have demonstrated that atypical antipsychotics are efficacious in the treatment of the aggressive and psychotic symptom clusters, and here we review their use in this indication. Because of the safety concerns associated with the use of atypical antipsychotics in this population, these drugs must be used judiciously. For patients with severe BPSD such as psychosis, agitation, or aggression, for whom there are few options, atypical antipsychotics, particularly risperidone and olanzapine, should be considered.