Common BPSD in early dementia

1. 2. 3. 4. 5. 6. 7. Definition Consequences Prevalence Presentation in early dementia Presentation in dementias of different origin Treatments Conclusions

EAMA 01.2006 & SBMI 12.2006

1. BPSD definition
International Psychogeriatric Association 1996 Consensus Conference: BPSD Behavioral and Psychological (Signs and) Symptoms of Dementia
describes a heterogenous range of psychological reactions, psychiatric symptoms and behaviors occuring in people with dementia of any etiology
IPA BPSD 2002 EAMA 01.2006 & SBMI 12.2006

2. BPSD Consequences
Decreased QOL patient, family, caregivers Increased caregiver burden Over-medication Premature institutionalisation Physical restraint High cost
Finkel S.I. Clin GeriatrMed 19 (2003) 799-824
EAMA 01.2006 & SBMI 12.2006

3. BPSD prevalence
In 90 % of demented people Reisberg et al. 1989 Almost all demented patients suffer from BPSD during a period Hope, Reine 1999 BPSD often brings up diagnosis dementia
Assal, Cummings 2002

EAMA 01.2006 & SBMI 12.2006

4. BPSD presentation in early dementia

Behavioral
Aggressive verbal: screaming, cursing physical: hitting, scratching Nonaggressive verbal: repetitive questioning physical: wandering, shadowing, taking away things, resistance to care

Psychological
Affect-mood anxiety, depressive symptoms apathy irritability Thought, perception delusions hallucinations misperceptions Vegetative symptoms sleep disturbances sexual behavior appetite
Desai, Grossberg 2001

EAMA 01.2006 & SBMI 12.2006

BPSD : changes over time

100

frequency (% patients)

80
Diurnal rhythm

Agitation Irritability Aggression Wandering Anxiety Accusatory Hallucinations Mood change Socially unaccepted Delusions Sexually inappropriate

60 40

Depression Social withdrawal Paranoia

20 0 40

Suicidal ideation

0 30 20 10
EAMA 01.2006 & SBMI 12.2006

10

20

30

Months before diagnosis

Months after diagnosis

Jost & Grossberg, 95, 96

Common BPSD in early dementia

Aggression verbal: screaming, cursing physical: hitting, scratching Nonaggressive behavior verbal: repetitive questioning physical: wandering, shadowing taking away things, resistance to care Social withdrawal Affect-mood anxiety depressive symptoms apathy irritability Thought, perception delusions hallucinations Vegetative symptoms sleep disturbances sexual behavior appetite

EAMA 01.2006 & SBMI 12.2006

BPSD in early dementia

Apathy symptoms (frontally-mediated) arise early and persist 42% in mild dementia Landes et al 2001, Ready et al 2003 Affective symptoms (depression, anxiety) occur early in the course of dementia and can disappear
Reisberg 89, Rubin 88, IPA 2002
EAMA 01.2006 & SBMI 12.2006

5. BPDS in different types of dementia

Lewy Body Dementia hallucinations (depression) Finkel 2003 Fronto-temporal Lobe Dementia apathy, aggression Alva, Potkin 2003 Vascular Dementia (small vessel disease) depression Ballard 1996, Finkel 2003 Early onset vs late onset
more BPSD !
Jost, Grossberg1996, Finkel 2001

EAMA 01.2006 & SBMI 12.2006

6. BPSD treatment
Many behavioral disturbance are not amenable to pharmacotherapy (wandering, hoarding); some can be improved Non-pharmacological interventions (mild moderate stages) : educating family, caregivers
Desai, Grossberg 2001

EAMA 01.2006 & SBMI 12.2006

BPSD in early dementia, Pharmacologic treatment

Target Symptom
Hallucinations, aggression Depression Anxiety, agitation, sleep dist. Recurrent agitation, disruptive behavior All BPSD domains

Drugs
Atypical antipsychotics SSRI Benzodiazepines Anticonvulsivants, atyp. antipsychotics
Finkel 2001, Lee 2004

Acetylcholinesterase inhibitors ?
Finkel 2004
EAMA 01.2006 & SBMI 12.2006

Common BPSD in early dementia Conclusions

Social withdrawal and apathy are early symptoms in dementia, often present before diagnosis. Affective symptoms (e.g. depression, anxiety) occur early (and more often in vascular dementia.) Recognising BPSD in early dementia is important for education and treatment. Therapy in BPSD should be aimed at target symptoms. For all behavior domains, cholinesterase inhibitors seem promising.
EAMA 01.2006 & SBMI 12.2006