Clinical Geriatrics

Behavioral and psychological symptoms of dementia (BPSD) is a term used to describe a heterogeneous group of noncognitive symptoms and behaviors that occurs in people with dementia.1 The term BPSD was defined by the International Psychogeriatric Association at the Update Consensus Conference, entitled “Behavioral and Psychological Symptoms of Dementia (BPSD): A Clinical and Research Update,” held in May 1999, as “Symptoms of disturbed perception, thought content, mood or behavior that frequently occur in patients with dementia.”2 The various behavioral symptoms described include physical aggression, restlessness, agitation, wandering, culturally inappropriate behaviors, sexual disinhibition, hoarding, and cursing. The various psychological symptoms described include anxiety, depressed mood, delusions, and hallucinations.2 BPSD leads to increased suffering, early institutionalization, increased cost of care, and causes significant loss in the quality of life for the patient’s caregivers and family.3

PREVALENCE
About two-thirds of people with dementia experience some BPSD at some point during the course of their illness.1 The figure may rise to 70-80% among patients with dementia who reside in nursing homes.4 Prevalence estimates may vary widely because of the heterogeneity of the patient population studied and the different definitions used to define BPSD. Margallo-Lana et al5 found a prevalence of 79% in people with dementia living in long-term care facilities. Ikeda et al6 found a prevalence of 88% in elderly people with dementia living in a Japanese community. BPSD tends to fluctuate, with psychomotor agitation being the most persistent symptom.7

All aspects of BPSD are associated with caregiver burden, but paranoia, aggression, and sleep disturbance appear to be particularly distressing.8 It is also associated with a worse prognosis and a more rapid rate of progression of disease.9 While mild Alzheimer’s disease (AD) is associated with subtle changes such as depression, moderate AD is associated with problems such as delusions, agitation, apathy, dysphoria, anxiety, and aberrant motor behavior.10

BACKGROUND
There are no Food and Drug Administration (FDA)-approved treatments for the behavioral and psychological symptoms of agitation associated with dementia. The mainstay of treatment for BPSD has been the antipsychotic agents. The FDA recently analyzed data from 17 placebo-controlled trials of atypical antipsychotics, and determined that the rate of death for elderly patients with dementia treated with an atypical antipsychotic agent was approximately 1.6-1.7 times that of those treated with placebo.11

The most common cause of death was cardiac-related events or pneumonia. The FDA has issued a “black box” warning on all atypical antipsychotic agents on the basis of evidence that their use leads to increased mortality for elderly patients.11 This has made the need for agents other than antipsychotic drugs even more compelling for the treatment of behavioral symptoms in the absence of delusions or hallucinations.

EVALUATION AND MANAGEMENT
Careful inquiry must be made regarding the presence of BPSD. Recognition of BPSD is the first and most important stage. A detailed history and examination are essential. This can be facilitated by use of standardized assessment scales such as the Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD)12 or the Neuropsychiatric Inventory (NPI).13 A reliable informant, preferably a caregiver who has daily contact with the patient, is required to complete these assessments accurately.

The characteristics of the behavior along with frequency, severity, and impact on patients and caregivers must be identified. It is also important to identify the main problems—primarily agitation and sleep disturbance. The content of the behavior and its impact also needs to be assessed (Table).