Improving Pharmacologic Management of Behavioral and Psychological Symptoms of Dementia (BPSD): An Algorithm for Real-World Care

Abstract

The Psychopharmacology Algorithm Project at the Harvard South Shore Psychiatry Residency Training Program (www.psychopharm.mobi) aims to capture the essence of the available evidence on pharmacotherapy treatment of various psychiatric disorders. This presentation focuses on our recently published BPSD algorithm which will be updated to the time of the meeting. Major factors considered in the review included efficacy, side effects, and amount of evidence supporting the medication. Speakers will explain how this algorithm should be interpreted and utilized. Ample time will be available for questions and answers.Geriatric patients with dementia frequently present to psychiatrists and geriatricians with agitation, aggression, psychosis, and other psychological symptoms of dementia. We present an update of our previously published algorithm for the use of psychopharmacology in these patients, taking into account more recent studies and recommendations from meta-analyses, reviews, and other published algorithms. We propose three algorithms: one for BPSD in an emergent setting, one for an urgent setting, and another for non-emergent settings. In the emergent setting, the clinician, patient, or others are in imminent danger due to behaviors related to BPSD and rapid response is required. In the urgent BPSD setting, the patient is symptomatic, but there is the potential to wait for a few days to weeks for improvement. In the non-emergent setting, the patient does not appear to be at imminent risk of putting him/herself or others at harm but has a history of such behaviors which interfere with care or quality of life.Emergency management often requires intramuscular medication (IM) administration., Our first-line recommendation is olanzapine (IM aripiprazole, favored in our previous version, is no longer available). Haloperidol IM is the second choice, followed by consideration of IM benzodiazepine. In the urgent algorithm, when oral treatments are possible, first line recommendations are the second-generation antipsychotics (SGAs) aripiprazole and risperidone. We review the evidence for also considering prazosin and electroconvulsive therapy as alternatives. There are hazards associated with all of these agents, including increased risk of mortality, which are discussed. Dosing strategies, discontinuation considerations, and side effects will also be discussed. In the non-emergent setting, we recommend first decreasing anti-cholinergic load, optimizing pain management, and improving sleep. Medication options are proposed for use in the following order: trazodone, donepezil and memantine, the selective serotonin reuptake inhibitors escitalopram and sertraline, SGAs (aripiprazole and risperidone), prazosin, and carbamazepine. Finally, other emerging options with insufficient evidence to include in the algorithms but with potential future promise are also discussed.