Guideline sources The following summarized guidelines for the evaluation and management of behavioral and psychological symptoms of dementia (BPSD) are prepared by our editorial team based on guidelines from the American Geriatrics Society (AGS 2015), the Canadian Geriatrics Society (CGS 2012), and the American Psychiatric Association (APA 2007). 1 2 3 4 5 5 6 Definition BPSD (BPSD) is a heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors occurring in people with dementia of any etiology. 4 Epidemiology BPSD are caused due to a complex interplay of psychological, social, and biological factors including neurochemical, neuropathological and genetic factors. 5 Disease course The complex interaction of psychosocial and biological factors results in BPSD, which have clinical manifestations of agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. Disease progression is associated with poor quality of life, distress among patients and caregivers, long-term hospitalizations, medication misue,a nd increased health-care costs. 5 https://web.pathway.md/diseases/recZCjq4k7lbY7KFO 1/4 6/29/23, 3:16 AM Behavioral and psychological symptoms of dementia Pathway Prognosis and risk of recurrence Moderate and severe BPSD are associated with an increased risk of mortality with HR 1.31 (95% CI, 1.08-1.60) and 1.74 (95% CI 1.44-2.12), respectively. 6 Pathway Behavioral and psychological sy Management Guidelines 1. Diagnostic investigations General principles: undertake a careful evaluation for general medical, psychiatric, environmental, or psychosocial problems that may underlie the disturbance. A 2. Medical management Initial management: evaluate for general medical, psychiatric, environmental, or psychosocial problems that may underlie the behavioral and psychological symptoms, and manage any underlying causes appropriately. A Pharmacologic treatment: As per Choosing Wisely 2015 guidelines, avoid antipsychotics as a first-line therapy for BPSD. D As per APA 2007 guidelines: Consider the judicious use of psychotropic agents in patients with BPSD in whom nonpharmacologic measures are unsuccessful, or if the behaviors are particularly dangerous or distressing. C Implement environmental measures, such as reassurance and redirection, to address persistent symptoms that do not cause significant danger or distress to the patient or others. A Antipsychotic agents: As per CGS 2012 guidelines, consider using risperidone, olanzapine and aripiprazole for the treatment of severe agitation, aggression and psychosis associated with dementia where there is risk of harm to the patient and/or others. B As per APA 2007 guidelines, consider using antipsychotic medications for the treatment of psychosis in patients with dementia. C Show 2 more https://web.pathway.md/diseases/recZCjq4k7lbY7KFO 2/4 6/29/23, 3:16 AM Behavioral and psychological symptoms of dementia Pathway Benzodiazepines: as per APA 2007 guidelines, consider using benzodiazepines in treating patients with prominent anxiety, who may derive a modest benefit from their use. C Other pharmacologic agents: As per CGS 2012 guidelines, insufficient evidence to make a recommendation regarding the use of cholinesterase inhibitors and/or memantine for the treatment of neuropsychiatric symptoms as a primary indication. I As per APA 2007 guidelines, avoid off-label use of anticonvulsants, lithium, or -blockers for the treatment of psychosis or agitation in dementia, except for patients in whom all other treatments have failed. D 3. Nonpharmacologic interventions Use of restraints: Use physical restraints for the management of behavioral symptoms of dementia only in patients who pose an imminent risk of physical harm to themselves or others. A Avoid physical restraints in patients who do not pose an imminent risk of physical harm to themselves or others. D 4. Follow-up and surveillance Re-evaluation of pharmacologic treatment: reevaluate the use of psychotropic agents and document their benefit on an ongoing basis. A Clinical findings Symptoms Neurological exam Aggression Mood alteration Delusions Depression Difficulty sleeping Hallucinations Repetitive behaviour Social inappropriateness Wandering References 1. APA Work Group on Alzheimer's Disease and other Dementias, Rabins PV, Blacker D et al. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Second edition. Am J Psychiatry. 2007 Dec;164 12 Suppl):5 56. Open https://web.pathway.md/diseases/recZCjq4k7lbY7KFO 3/4 6/29/23, 3:16 AM Behavioral and psychological symptoms of dementia Pathway 2. Gauthier S, Patterson C, Chertkow H et al. Recommendations of the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia CCCDTD4 . Can Geriatr J. 2012 Dec;15 4 120 6. Open 3. American Geriatrics Society. Choosing Wisely: Recommendations of the American Geriatrics Society. Choosing Wisely. 2015 Apr. Open 4. S Shaji, Srija Bose, Shan Kuriakose. Behavioral and psychological symptoms of dementia: A study of symptomatology. 2009 Jan;51 1 38 41.2009 Jan;51 1 38 41. Open 5. J Cerejeira, L Lagarto, E B Mukaetova-Ladinska. Behavioral and psychological symptoms of dementia. 2012 May 7;3 73.2012 May 7;3 73. Open 6. Vanja Bransvik, Eva Granvik, Lennart Minthon et al. Mortality in patients with behavioural and psychological symptoms of dementia: a registry-based study. 2020 Feb 18;1 9.2020 Feb 18;1 9. Open 7. Reus VI, Fochtmann LJ, Eyler AE et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. Am J Psychiatry. 2016 May 1;173 5 543 6. Open 8. American Academy of Neurology. Choosing Wisely AAN recommendations. Choosing Wisely. 2014. Open https://web.pathway.md/diseases/recZCjq4k7lbY7KFO 4/4