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
(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
(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
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
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.
Starting dose
Usual dose



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