Managing behavior problems in patients with dementia
Managing Behaviour and Psychological Problems in Patients with Diagnosed or
S anagement guidelines for people over 65 with diagnosed or
uspected dementia in Nottingham and Nottinghamshire
s Rowan Harwood, geriatrician, Nottingham University Hospitals
Jonathan Waite, psychiatrist, Nottinghamshire Healthcare Trust
John Lawton, pharmacist, Nottinghamshire Healthcare Trust
Esther Gladman, GP, Prescribing Lead, Nottingham City PCT/CCG
Approved by Nottinghamshire Area Prescribing Committee (NAPC)
Based on original work done by Hampshire Partnership NHS Foundation Trust, and NHS East Midlands
A reference list is available on request
MANAGING BEHAVIOUR AND PSYCHOLOGICAL PROBLEMS IN PATIENTS WITH DIAGNOSED OR SUSPECTED DEMENTIA (Does not cover rapid tranquillisation of acutely disturbed patients) Quick points
1. Patient with dementia with Behavioural and Psychological Symptoms of Dementia (BPSD) – consider delirium – review all medication – identify and address provoking/exacerbating factors and physical health
– if unresolved develop a person‐centre care plan with family/carers – try watchful waiting, symptoms may resolve without intervention over a
– if considering drug treatment, first identify dominant target symptom – initiate drug therapy appropriate to target symptoms – review at 6 weeks then every 3 months – actively try withdrawing/stopping the drug – some symptoms do not respond to drug treatment e.g. wandering,
2. Key messages for secondary care – always communicate drug changes to the GP – provide a reason for each prescription for BPSD – request a review of drugs prescribed for BPSD every 3 months and try
3. Key message for GPs and primary care – on‐going antipsychotic prescriptions require a prescribing care plan – for patients in care homes, consider referral to the Dementia Outreach
Teams (Nottinghamshire Healthcare Trust) if simple measures ineffective
– review all drugs prescribed for BPSD every 3 months and try
– pharmacists are in an ideal position to support GPs and request
4. This is a complex and contentious area. These are guidelines. They may
not always apply in each individual clinical situation. Please use your professional judgement.
MANAGING BEHAVIOUR AND PSYCHOLOGICAL PROBLEMS IN PATIENTS WITH DIAGNOSED OR SUSPECTED DEMENTIA (Does not cover rapid tranquillisation of acutely disturbed patients)
disorders), & review medication.
Follow guidelines for delirium e.g. NICE
Write a care plan. Consider person centred approaches. Involve
Identify, document and address provoking or
family carers for information and help with care. Collect
information on biography, preferences and routines. Understand
- Physical problems: pain, constipation, urinary
what the person with dementia experiences. Develop a
relationship to relieve anxiety. Repeat explanation and
- Activity-related: boredom, misinterpretation of care tasks
reassurance frequently (up to every 30 mins). Don’t confront,
- Treatment related: catheters, monitors, infusions,
punish or humiliate. If agitated try ‘leave & return’, distraction
activity (matched to level of ability), or one-to-one care. Consider
- Environment: noise, temperature, lighting, change
watchful waiting for 2 or 3 days. Patients may settle.
Identify the dominant target symptom group
- Psychosis: delusions or hallucinations (but care
Consider pharmacological treatment if there is distressing
over ‘delusions’ due to forgetfulness)
psychosis, or behaviour that is harmful or severely distressing to
the individual or puts others at risk. Continue person-centred approaches.
- Emotional liability; distress (e.g. crying, anger)
Could this be Dementia with Lewy Bodies or Parkinson’s
Disease Dementia? Key features: Parkinsonism, visual
hallucinations, delusions, fluctuation. If unsure get specialist
General guidelines if pharmacological treatment is indicated
Both typical and atypical antipsychotics worsen cognitive function, increase risk of stroke (3x) and death (2x), and can significantly reduce quality of life. They should only be used after discussion with the patient (if s/he has capacity to
understand) or family carer about possible benefits and risks. Risk increases with age and vascular risk factors, and in established cerebrovascular disease. If antipsychotic treatment is necessary, start at low dose and increase slowly every 2-4 days if no response. Always review for effects and side-effects. Patients with Dementia with Lewy Bodies or Parkinson’s Disease Dementia are particularly vulnerable to antipsychotic sensitivity reactions and extrapyramidal side effects. Extreme caution is required.
Patients who respond to treatment should be reviewed after 6 weeks. Consider withdrawal: halve the dose for one week and
if no worse stop the drug. Review after 1 week. If the symptoms re-emerge reintroduce the drug at starting dose. Over half of BPSD resolve within 6 months. However, BPSD can persist and treatment with antipsychotics may be needed in the long
term, but should be reviewed 3 monthly. Secondary care prescribers: Communicate drug changes to the GP. Provide a reason for each prescription. Request a review every 3 months. Primary care prescribers: Antipsychotic prescriptions require a prescribing care plan. Try withdrawing/stopping the drug after 3 months. For patients who have been taking antipsychotics long-term a more cautious reduction over 4-6 weeks or longer, depending on the individual, is recommended. If problems are ongoing, refer to Community Mental Health, or the care home Dementia Outreach Teams (via Single Point of Access). Alzheimer’s Disease Key Symptom First Line Second Line
Olanzapine (5), Quetiapine (5), Haloperidol,
Olanzapine (5), or Memantine (6) ± short term
symptoms or problems. No specific drug treatment.
Dementia with Lewy Bodies (LBD) or Parkinsons Disease Dementia (PDD) Key Symptom First Line Second line
Rivastigmine (5) or Memantine (6) ± short term
symptoms or problems. No specific drug treatment.
NOTES (1) The largest trial showed sertraline and mirtazapine to be ineffective for treating depression in Alzheimers disease. (2) The evidence base for treating psychosis is poor. Antipsychotics will not work for ‘understandable delusions’ caused by forgetfulness, such as ‘living in the past’. (3) Sleep disturbance or sleep reversal is very common. Maximise daytime activity. A trial of hypnotics may be justified. May need longer than recommended treatment duration if symptoms persist. (4) Quetiapine and SSRIs may worsen motor symptoms of PD. (5) Amber 2 traffic light classification – refer to NAPC prescribing information sheets. Risperidone is the only oral atypical antipsychotic licensed for the short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate-to-severe Alzheimer’s Dementia. (6) Amber 1 traffic light classification – refer to NAPC shared care protocol. Vascular dementia or stroke-related dementia and other dementias There is little evidence base for the treatment of BPSD in vascular and other dementias. Prescribers are advised to follow the guidance for Alzheimer’s Disease. Specialist advice may be required, especially for rare dementias such as fronto-temporal dementias. Drug dose guidelines for use of antipsychotics in dementia This needs to be judged according to the situation, including severity of symptoms, previous responses to drugs, and general physical fitness or frailty. Small doses for small people. Antipsychotic Starting dose Usual dose
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