Interventions for non-cognitive symptoms and challenging behavior
Also known as neuropsychiatric symptoms or 'behavioural and psychological symptoms of dementia' (BPSD), this term includes
- non-cognitive symptoms - delusions, hallucinations, depression, anxiety, apathy
- behaviour that challenges - aggression, agitation, wandering, hoarding, sexual disinhibition, apathy and disruptive vocal activity such as shouting (1)
People with distressing non-cognitive symptoms and behaviour that challenges should be assessed as early as possible to identify factors that may generate, aggravate or improve such behaviour (1)
- this should cover:
- the persons physical health
- depression
- possible undetected pain or discomfort
- side effects of medication
- individual biography - religious beliefs, spiritual and cultural identity
- psychosocial factors
- physical environmental factors
- behavioural and functional analysis should be carried out by health professionals with specific skills, together with carers and care workers (1)
- individualised care plan should be developed, recorded in the notes and reviewed regularly which will aid the carers and staff to deal with the patients behaviour (1)
Non pharmacological In people with dementia (all types and severities) and concomitant agitation, the following interventions should be offered according to the preferences, skills and abilities of the patient:
- aromatherapy
- multi sensory stimulation - producing a multi sensory environment using light effects, relaxing music, recorded sounds, massage cushions, tactile surfaces, and fragrances (2)
- therapeutic use of music and dance
- animal assisted therapy
- massage (1)
The response to each intervention should be monitored and changes may be done accordingly (1).
Pharmacological
Pharmacological therapy should be offered to patients who are severely distressed or if there is an immediate risk of harm to themselves or others (1)
- this should be followed by the assessment and care planning approach (including bahavioural management) as soon as possible
- in patients with less severe distress and/or agitation, pharmacological interventions should be considered only after failure of above mentioned non-pharmacological approaches (1).
NICE state that with respect to agitation, aggression, distress and psychosis (2):
- only offer antipsychotics for people living with dementia who are either:
- at risk of harming themselves or others
- or experiencing agitation, hallucinations or delusions that are causing them severe distress
- be aware that for people with dementia with Lewy bodies or Parkinson's disease dementia, antipsychotics can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions
- before starting antipsychotics, discuss the benefits and harms with the person and their family members or carers (as appropriate)
- when using antipsychotics:
- use the lowest effective dose and use them for the shortest possible time
- reassess the person at least every 6 weeks, to check whether they still need medication
- stop treatment with antipsychotics:
- if the person is not getting a clear ongoing benefit from taking them and
- after discussion with the person taking them and their family members or carers (as appropriate)
- valproate should not be used to manage agitation or aggression in people living with dementia, unless it is indicated for another condition
Depression and anxiety (2)
- consider psychological treatments for people living with mild to moderate dementia who have mild to moderate depression and/or anxiety
- antidepressants should not be routinely used to manage mild to moderate depression in people living with mild to moderate dementia, unless they are indicated for a pre-existing severe mental health problem.
Sleep problems (2)
- melatonin should not be used to manage insomnia in people living with Alzheimer's disease
- for people living with dementia who have sleep problems, consider a personalised multicomponent sleep management approach that includes sleep hygiene education, exposure to daylight, exercise and personalised activities.
Drug treatments are symptomatic in most cases:
- antipsychotics for restlessness and agitation include:
- conventional psychotics such as haloperidol - note that there is evidence that risperidone and olanzapine are associated with an increased risk of cerebrovascular events when used in the treatment of dementia in the elderly and are not recommended in this patient group (3,4). Guidance concerning the management of behavioural and psychiatric symptoms in dementia and the treatment of psychosis in people with a history of stroke/TIA is linked
- antidepressants, anxiolytics and hypnotics should only be used in patients with relevant marked and persistent symptoms (3)
- acetylcholinesterase inhibitors could be considered in
- patients with mild, moderate or severe Alzheimer's disease who have non-cognitive symptoms and/or behaviour that challenges causing significant distress or potential harm to the individual when both non pharmacological and pharmacological treatment methods are inappropriate or ineffective
- people with DLB who have non-cognitive symptoms causing significant distress or leading to behaviour that challenges
- people with vascular dementia who are participating in constructed clinical studies (1)
NICE have given guidance as to the use of cholinesterase inhibitors in Alzheimer's disease - although the routine use of drugs with pronounced anticholinergic effects may worsen cognitive function or precipitate delirium (3).
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