Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD)

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This tool is designed to help providers understand, assess, and manage residents in primary care and LTC homes with behavioural and psychological symptoms of dementia (responsive behaviours), with a focus on antipsychotic medications. It was developed as part of Centre for Effective Practice’s Academic Detailing Service for LTC homes. This tool integrates best-practice evidence with clinical experience, and makes reference to relevant existing tools and services wherever possible.

Important principles include:

  • Being patient/resident-centred,
  • Being mindful of benefits, risks and safety concerns,
  • Using an interprofessional team approach and validated tools,
  • Prescribing conservatively, and,
  • Reassessing regularly for opportunities to deprescribe medications that are no longer needed.

As always, efforts must be made to individualize any treatment decisions for the resident, with consideration given to caregivers, family members, as well as LTC staff.

Identify BPSD Symptom Clusters1, 2

Pyschosis
  • Delusions
  • Hallucinations
  • Misidentification
  • Suspicious

Agression
  • Defensive
  • Resistance to care
  • Verbal
  • Physical

Agitation
  • Dressing/undressing
  • Pacing
  • Repetitive actions
  • Restless/anxious

Depression
  • Anxious
  • Guilty
  • Hopeless
  • Irritable/screaming
  • Sad, tearful
  • Suicidal

Mania
  • Euphoria
  • Irritable
  • Pressured speech

Apathy
  • Amotivation
  • Lacking interest
  • Withdrawn

Treatment for dementia is an ongoing process. Since dementia is a progressive disease, regular follow-ups are necessary to ensure that the patient/resident is receiving the best possible treatment for his or her symptoms. The sections in this tool should each be considered at each follow-up (even if some treatments discussed, such as drug therapy, will not be necessary for every patient/resident at every stage of treatment).

Section A: Evaluate BPSD

Before beginning any sort of treatment (e.g. drug or non-drug therapy), it is important to evaluate the patient’s/resident’s symptoms.

This section discusses:

  • Tools for discussing and documenting BPSD
  • How to use the P.I.E.C.E.S.TM tools to assess risks to the resident and others
  • Clinical evaluations that should take place in order to identify any underlying physiological causes of BPSD

Remember: Engage the family/caregiver at every step. Discuss any history that may help the care team understand and manage the behaviour (e.g., preferences, activities, routine).

Assess & Document

  • Document behaviour or symptom clusters, including frequency, severity, triggers, and consequences
  • Document any potential reversible causes (e.g. delirium, depression)
  • Designate specific members of the interprofessional care team who will be responsible for coordinating day-to-day assessment and management
  • Standardized clinical assessment tools, such as the Antecedent, Behaviour, Consequence (ABC) Chart Form3 and Dementia Observation System (DOS)4 can be helpful for monitoring and documenting symptoms
  • Examples of standardized clinical assessment tools can be found in Supporting materials

Identify Risks

  • Use the P.I.E.C.E.S.TM RISKS mnemonic to assess risks to the resident and others:9
    • Roaming: Is risk greater due to resident roaming?
    • Imminent: Is significant risk imminent?
    • Suicide: Does the resident display any suicidal tendencies?
    • Kin: Is the health or safety of residents/caregivers affected?
    • Self-neglect: Is resident’s self-neglect a risk to themself or others?
  • Interview family/caregiver independently to ask about family/caregiver strain and risk of abuse by patient
  • Be mindful of any suggestions of patient abuse by family/caregivers

Identify BPSD Causes

  • Obtain history from caregivers, family, and staff10
  • Consider environmental factors and triggers, including possible role of team members
  • Consider using P.I.E.C.E.S.TM to identify causes (see box on right)
Talking points

Use the P.I.E.C.E.S. 3-Question Template TM to ask:

  1. What has changed?
  2. What are the RISKS and possible causes?
  3. What is the action?
Use P.I.E.C.E.S.TM to Identify Causes 9
Click to view P.I.E.C.E.S.TM RISKS

Clinical Evaluation10

The differential diagnosis of the syndrome of behaviour change in dementia is broad. Careful examination of history, physical examination and appropriate investigations may help identify contributing factors. A full, rather than targeted, physical examination is indicated, within the bounds of patient cooperation.

History (include family/caregivers):
  • Recent changes to environment, routine, sleep pattern, family/social situation
  • Medication Review:
    • Adherence,prescription and OTC medications, anticholinergic load, drugsthat may increase agitation (e.g. cholinesterase inhibitors), medication induced hypotension or orthostatic hypotension, medication that may contribute to constipation and urinary retention, drugs and/or alcohol
Physical Examination:

Be mindful of sources of:

  • Pain (e.g. dental, skin, joint, feet)
  • Hydration (e.g. dehydration)
  • Sensory loss (hearing, vision)
  • CNS change (e.g. new stroke)
  • Infection (e.g. pneumonia, urosepsis)
  • Hypo-perfusion (e.g. new atrial fibrillation, heart failure)
  • Constipation and urinary retention
Laboratory and Imaging (as guided by physical exam/history):
  • Blood: Glucose, calcium, complete blood count (CBC), creatinine, electrolytes,TSH, others as appropriate
  • Urine: Any urinary symptoms? (Note: Caution not to send urine for culture if no urinary symptoms or sudden change in status as “asymptomatic bacteriuria” without lower urinary tract symptoms or symptoms of urosepsis/bacteremia are rarely the cause of increased behavioural symptoms)
  • Imaging: If appropriate (e.g. chest x-ray if suspected pneumonia based on physical exam; CT head if new concerning neurologic findings

Section B: Initiate Non-Drug Therapy for BPSD

Non-drug therapy is an important part of managing BPSD, regardless of whether drug therapy is initiated. It is an ongoing process that involves the care team, family, and caregivers.
This section discusses:

  • Safety, environmental, and caregiver approach considerations that are core components of non-drug therapy
  • Possible solutions to behavioural symptoms, including those identified within the Dementia Observation System (DOS)
Tips for successful non-drug therapy
  • As a general principle, individualize your approach as much as possible. Behavioural triggers and effective ways to treat them will vary from one resident to the next.
  • Take advantage of any available system supports, such as Behavioural Supports Ontario (BSO) and Psychogeriatric Resource Consultants (PRCs).14
  • Even if non-drug therapy is successful at managing symptoms (i.e. drug therapy is unnecessary), monitor targeted behaviours for changes and follow-up regularly based on the needs of the resident/caregiver and severity of symptoms.
Safety
  • Ensure the resident’s safety and other residents’ safety by securing the environment
  • Make sure you are safe (exit near, chair between you and resident)
  • Remove potentially dangerous objects
  • Move other individuals away
  • Remove ongoing triggers
Environmental Considerations
  • Eliminate misleading stimuli
    • Clutter, TV, radio, noise, people, reflections in mirrors/dark windows, pictures/décor
  • Reduce environmental stress
    • Caffeine, extra people, holiday decorations, public TV
  • Adjust stimulation
    • If over-stimulated, reduce noise, activity, confusion
    • If under-stimulated, increase activity/involvement
  • Enhance function
    • Increase lighting, to reduce misinterpretation
    • Add signs, cues, or pictures to promote way-finding
  • Adapt the physical setting according to individual preference
    • Secure outdoor areas
    • Home-like features
    • Smaller, segmented recreational and dining areas
    • Spa-like bathing facilities
Caregiver Approach Considerations
  • Personal approach
    • Be calm and compassionate (use/avoid touch as indicated)
    • Distract by engaging in individualized activities
    • Focus on resident’s wishes, interests, concerns
    • Approach slowly; look for signs of increase agitation
    • Approach resident’s private space slowly and ask permission prior to entering
  • Daily routines
    • Keep to the same routine to reduce uncertainty
    • Use long-standing history and preferences to guide
    • Individualize social and leisure activities to reduce boredom
  • Communication style
    • Most communication is non-verbal, use positive non-verbal cues
    • Make eye contact unless perceived as aggressive
    • Use short simple words and phrases (residents with dementia have trouble processing multiple words)
    • Speak clearly and use a positive tone
    • Wait for answers (be patient)

Section C: Consider Drug Trial(s)

Section D: Additional Information on Antipsychotic Therapy

Supporting materials

Reference

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