PROTOCOL FOR MANAGING BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS IN

PATIENTS WITH DEMENTIA

(Does not cover rapid tranquillisation of acutely disturbed)
Refer to Cumbria Dementia strategy for prevention strategies and initial non-
pharmacological management

A) Primary care responsibility B) Optional primary care responsibility with secondary

care support if required or requested C) Secondary care responsibility

A) Patient
Patient hashas Behavioural
Behavioural andand Yes Does patientalso
Does patient have a a
have Yes Treat underlying acute
Yes Yes
Psychiatric Symptoms
Psychological Symptomsin Dementia
in Dementia Delirium?
Delirium? medical problems e.g.
(BPSD) (delusions, hallucinations,
(e.g. psychosis; aggression; (Short history<<21weeks
(Short history week UTI, chest infection,
agitation,
depression aggression,
combined irritability etc with
with a decline in confusion, hallucination,
hallucinations, delusions or side effects of drugs,
steady decline
cognition in cognition
over six month) over a delusion with
apathy with fluctuating
fluctuating alcohol and drug
minimum of 6 months) cognition)
cognition) withdrawal etc.

No
No
Behavioural problems
B) Apply PAAID approach and manage or treat: unresolved
Apply PAIN approach and manage or treat:
P=Physical
P=Physical problems
problems e.g.
e.g. infection,
infection, pain
pain
A=Activity-related
A=Activity-related e.g.dressing,
e.g.dressing, washing
washing
A= Anti-cholinergic
I =Iatrogenic burden-
e.g. side effectssee CPFT e.g.
of drugs Shared Medicines
anticholinergics Consider non-pharmacological approaches such
Resources on Medicines Management homepage
N= Noise and other environmental factors e.g. lighting.(link on p3) as: distraction, leave & return, activity, one-to-one
I=Intrinsic to dementia e.g. wandering care, music, aromatherapy. Carer support may
D=Depression, anxiety and psychosis improve coping ability of carer(s).
Refer to Cumbria dementia strategy for further
information
Identify the dominant target symptom group
Identify
Identify
IIIII
IIIII
Psychosis: Delusions/Hallucinations.
Only consider pharmacological treatment if there
Depression: depressed mood and /or loss of ability to enjoy is psychosis, depression or severe distress or an
previously pleasurable activities. May or may not include immediate risk of harm to the person or others. Do
apathy. NOT use for mild-moderate symptoms

Apathy: diminished motivation; listlessness; loss of drive to

engage in activities. May be perceived as laziness. Could this be Dementia with Lewy Bodies or
Parkinsons Disease Dementia?
Aggression Key features: long term (> 6 months) history of
vivid visual hallucinations or parkinsonism or
Agitation/ Anxiety fluctuating cognition.

Sleep disturbance Unsure Yes or No

Other symptoms: e.g. vocalisations; sexual disinhibition; C) Get specialist Follow guidelines
stereotypical movements etc. advice below and overleaf

In the event of General guidelines if pharmacological treatment is indicated.

continuing
problems, advice
can be obtained
from OA CMHT,
liaison team or
memory service
There is only one drug
(Risperidone) licensed
specifically for the
treatment of BPSD. For
other symptoms drugs
are used which have
either been shown to
improve these symptoms
in subjects without
dementia or are licensed
for cognitive
enhancement in patients
with dementia.
Approved Nov 2012
The use of either typical or atypical antipsychotics in patients with dementia worsens
cognitive function; increases the risk of cerebrovascular events (~ 3 xs) and increases mortality rate
(~2x). They should only be used after full discussion with the patient (where the patient has
capacity to understand) and carer about the possible benefits and likely risks. Risk is likely to
increase with increasing age and if other risk factors for cerebrovascular events are present e.g.
diabetes; hypertension, cardiac arrhythmias; smoking and existing evidence of stroke or vascular
dementia.
If antipsychotic treatment is considered necessary avoid typical antipsychotics. Start atypical doses
low (usually one half normal elderly dose) and increase every 2 -4 days if no response (see
specific doses suggestions p3)
Patients who respond to treatment should have the drug cautiously withdrawn after 6-12 weeks.
Gradually reduce dose and if no re-emerging symptoms, stop. Prescribe so that reductions and
discontinuation begin on a Monday. Review again one week after stopping. If symptoms re-emerge
reintroduce the drug at starting dose.
BPSD can persist and treatment with atypical antipsychotics may be needed in the long term but
should be reviewed on a 3 monthly basis.
Patients with Dementia with Lewy Bodies or Parkinsons Disease Dementia are particularly
vulnerable to antipsychotic sensitivity reactions and also have marked extrapyramidal side effects.
The management of antidepressants and hypnotics in patients with dementia has little
evidence base and should follow existing guidelines for the management of these drugs in elderly
patients without dementia. Treatment doses should follow BNF guidelines.
Memory Matters medication scrutiny tool (ref Cumbria Dementia strategy) can be used to record
symptoms, alternative treatments used, risk benefit assessment, medication prescribed, patient/
carer experience and review of therapy
Prescribing Guidelines for BPSD in Dementia

For all cases of agitation and aggression in dementia, pain relief i.e. Paracetamol 1g tds should be seriously considered
as an alternative to the medications below.
Husebo et al published a recent Norwegian study in the BMJ which showed analgesia significantly reduced
agitation/aggression compared to controls- BMJ 2011;343:d 4065- http://www.bmj.com/content/343/bmj.d4065

Alzheimers Disease.

Evidence Evidence
Key symptom First line Second line
type type
Depression Sertraline, 23+ Mirtazapine 3
Citalopram#
S
Apathy Sertraline, 23 + Donepezil ; Rivastigmine 2
S S
Citalopram# ; Galantamine
Psychosis Risperidone 1 Olanzapine; Aripiprazole; 2
S
Memantine
L
Aggression Risperidone 1 Olanzapine, Aripiprazole; 2
Haloperidol 2 Carbamazepine, 2
S
Lorazepam Memantine
Moderate Agitation/ Anxiety Citalopram. # 3 Trazadone; Lorazepam; 2-4
Mirtazapine; Memantine
Severe Agitation/ Anxiety Risperidone, 1 Aripiprazole, Olanzapine, 2-4
S
Memantine Lorazepam.
Poor sleep Temazepam; 3+ Zolpidem 3
Zopiclone.

Dementia with Lewy Bodies or Parkinsons disease dementia.

Evidence Evidence
Key symptom First line Second line
type type
Depression Citalopram# 4+ Sertraline 4
S
Apathy Sertraline, 4+ Donepezil ; 2
S
Citalopram# Rivastigmine ;
S
Galantamine
S S
Psychosis* Rivastigmine . 2-3 Quetiapine 3
S S
Donepezil ; Clozapine
S
Galantamine ..
S
Aggression Quetiapine. 3 Rivastigmine 3-4
S S
Donepezil ; Galantamine
Lorazepam
S
Moderate Agitation/ Anxiety Citalopram.# 3+ Rivastigmine . 2-4
S
Sertraline Donepezil
S
Galantamine Lorazepam
S
Severe Agitation/ Anxiety Quetiapine. 3 Rivastigmine 3-4
S S
Donepezil ; Galantamine
Lorazepam
Poor sleep Temazepam; 3+ Zolpidem 3
Zopiclone.
REM sleep behaviour Clonazepam** 3
(nightmares; hyperactivity)
* consider reducing antiparkinsonian medication first. ** 500-1000 microgram nocte
L S
= Licensed indication = Secondary care initiation or recommendation under shared care
# If considering Citalopram, note MHRA guidance (contra-indication with antipsychotic and max dose in elderly 20mg) (link on p 3)
Evidence levels: 1 = Meta-analysis; 2 = RPCTs; 3 = Other studies; 4 = Expert opinion; =cost

Please note the use of mood stabilisers/anticonvulsants has very limited evidence to support use. Use should be
restricted to patients where other treatments are contra-indicated or ineffective.

Vascular dementia or stroke related dementia.

There is little evidence base for the treatment of BPSD in Vascular dementia or stroke related dementia. The cholinesterase
inhibitors (Donepezil; Rivastigmine; Galantamine) and Memantine are not licensed for the treatment of vascular dementia and
should not be used. Prescribers are advised to follow the guidance for Alzheimers disease but to use with extreme caution drugs
with an established increased cerebrovascular risk (i.e. antipsychotics)

Other BPSD and other dementias (e.g. Fronto-temporal lobe dementia).

There is little evidence base for the treatment of other BPSD or for the treatment of common BPSD in other dementias.
Specialist advice should be sought.

Drug dose guidelines for antipsychotics and anxiolytics in dementia.

Approved Nov 2012
 Start at minimum recommended dose and titrate according to response (usually every 2-4 days) to maximum tolerated
dose. Cautious withdrawal may be initiated at 6-12 weeks. See guidelines on page 1 of this guidance.

Drug Starting dose Maximum dose

Risperidone** 500 microgram o.d.* 1mg b.d.
Olanzapine 2.5mg o.d. 10mg daily
Quetiapine 25mg o.d. 25-300mg daily
Aripiprazole 5mg o.d. 10mg daily
Haloperidol** 0.5mg bd-tds oral/IM 1mg tds oral/IM
Lorazepam 0.5 mg 1mg bd oral/IM 1mg bd oral/IM ***
* BNF dose250microgram bd
** Do not use haloperidol or risperidone in established or suspected Parkinsons disease or Lewy Body Dementia
*** elderly max dose

Citalopram and escitalopram warning letter MHRA November 2011

http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/Mo
nthlylistsofinformationforhealthcareprofessionalsonthesafetyofmedicines/CON134744

Anti-cholinergic burden- see Shared Medicines Resources on Medicines Management intranet pages
http://cptportal.cumbria.nhs.uk/SiteDirectory/MedicinesManagement/Web%20Pages/Shared%20Medicines%20Resources.
aspx

Further resources:

efns.org (European Federation of Neurological Societies)

ipa-online.org (International Psychogeriatric Association)

Approved: Cumbria Partnership NHS Foundation Trust Medicines Management Committee September 2012
Cumbria Area Prescribing Committee October 2012

Date for review November 2014 (or sooner if relevant guidance changes)

Based on 1.CSM CEM/CMO/2004/1(MHRA); 2.BNF (2008); 3.Faculty of Old Age Psychiatry (2008); 4. Maudsley Guidelines 2012; 5.NICE-SCIE guidelines;
6. SIGN 2006: 6. Ballard C , Current Opinions in Psychiatry 2009: Cochrane review of antipsychotics in dementia 2001/2010.
Acknowledgement to Prof C Holmes and Dr S Muthalagu, - March 2009 (Hampshire Guidelines), Dr S Wright, Ms Sue Wright, April 2011 (Rotherham guidelines)

Approved Nov 2012