BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA: UPDATE ON TREATMENTS, MECHANISMS AND MANAGEMENT IN THE CLINIC AND COMMUNITY

Abstract

Behavioral and Psychological Symptoms of Dementia (BPSD) are common and challenging, with no consistently effective pharmacological or non-pharmacological treatments available. Among psychotropics, atypical antipsychotics have the strongest evidence, but adverse effects and safety concerns often outweigh benefit. SSRIs are often better tolerated, and the strongest evidence is for citalopram, but QTc prolongation is a limiting factor. Evidence for mood stabilizers is weak. Some evidence supports the use of dronabinol, prazosin, and dextromethorphan/quinidine. Pimvanserin is FDA approved for psychosis in Parkinson's disease. Options for psychosis in Dementia with Lewy bodies include cholinesterase inhibitor, quetiapine, and clozapine. Some promising results have been reported with ECT for agitation and aggression in dementia. An algorithm approach for BPSD in Alzheimer's disease (AD) and mixed dementia has been used on several inpatient units in Canada. Insights into possible biological mechanisms of BPSD throughout the spectrum of AD severity may be useful for treatment development. Areas with the best evidence include depression, anxiety and apathy in preclinical and prodromal AD. BPSD are associated with a mix of “core” mechanisms and “non-core” mechanisms of AD and may be associated with the earliest stages of AD pathology, but data remains relatively sparse. Other factors contributing to BPSD include physical and social conditions, as well as the dynamic between caregivers and persons with dementia. The MIND at Home multidisciplinary intervention is designed to support persons with dementia and their caregivers at home. Features include: completing an in home patient and caregiver-centered dementia-related needs assessment, building an evidence based care plan around patient and caregiver-specific needs, a Memory Care Coordinator (MCC) providing dementia education, support and guidance to help the dyad prioritize and follow through on care plan recommendations, and a multidisciplinary clinical team supporting the MCC, with regular team meetings, with telephone and video visit access to other team members from patients’ homes. Prior studies demonstrate that dementia care co-management models contribute to better health-related quality of life, fewer behavioral symptoms of dementia, less severe functional and cognitive symptoms, reduce stress and depression in caregivers and lead to reduced utilization of acute care services. Imperative and opportunity exist for implementing an evidence-based model of integrated dementia care across a health care system that places an emphasis on quality and reducing health care costs. Partners HealthCare, a large and diverse health care system, is in the process developing and launching such a model.