1. Approaches to behavioral and psychological symptoms of Dementia
Marie-France Rivard, MD, FRCPC
Division of Geriatric Psychiatry
University of Ottawa

2. Objectives
Describe the causes of common psychological and behavioral symptoms in dementia (BPSD)
Introduce the purpose of the PIECES program
Identify appropriate interventions
Advise on the role of pharmacotherapy

3. Disclosure slide
Over last 28 years, received honoraria for Continuing education activities from most pharmaceutical companies and some grants for research.
Over last 7 years, no direct funding for research or Continuing Education: honoraria by organizing committees who may have, in turn, received un-restricted grants.
Currently Chair, Seniors Advisory Co to MHCC, mostly volunteer work.

4. Prevalence of BPSD
90% of patients affected by dementia will experience Behavioral and Psychological Symptoms of Dementia (BPSD) that are severe enough to be labeled as a problem during the course of their illness.
Agitation (75%) Wandering (60%) Depression (50%) Psychosis (30%) Screaming and violence (20%) are most common

5. Impact of BPSD
50 – 90% of caregivers considered physical aggression as the most serious problem they encountered and a factor leading to institutionalization. (Rabins et al. 1982)
Front-line staff working in LTC report that physical assault contributes to significant work related stress (Wimo et al. 1997)
Agitation, depression, anxiety, paranoid ideation cause significant suffering.

6. BPSD Symptom Clusters Aggression Agitation Apathy Mania Psychosis
Physical aggression
Verbal Aggression
Aggressive resistance
to care
Pacing
Repetitive actions
Dressing/undressing
Restless/anxious
Apathy
Withdrawn
Lacks interest
Amotivation
Euphoria
Pressured speech
Irritable
Hallucinations
Delusions
Misidentification
Suspicious
Sad
Tearful
Hopeless
Guilty
Anxious
Irritable/screaming
Suicidal
Mania
Psychosis
Depression
Adapted from McShane R. Int Psychogeriatr 2000;12(suppl 1): 147

7. Causes of BPSD What is P.I.E.C.E.S.
Person-centered assessment and care planning approach, using the care team to develop hypotheses and test the implementation of possible solutions.
An acronym that conveys the individuality and importance of the various factors that contribute to BPSD in dementia.
These factors are: Physical, Intellectual, Emotional, Capabilities, Environment and Social

8. P.I.E.C.E.S. Taught in Ontario since 1998 to LTC registered staff
From expanded to include administrators of LTC, unregistered staff, acute care hospitals, CCAC case managers
: PIECES program for physicians:
Soon available for distribution
To be tested with family health teams and utilized by Peer Presenters and Preceptors of Ontario’s Alzheimer strategy

9. Why use the P.I.E.C.E.S. approach?
Identification of target behaviors which present risk or urgency
Flags possible delirium
Framework for synthesis of non-pharmacologic approaches
Nutrition, comfort, hydration, sleep, etc…
Environment, personhood, social, stimulation
Guide the pharmacologic approach

10. PIECES Template The Three Question Template 1. What has changed?
2. What are the RISKS and possible causes (using the PIECES framework)?
3. What is/are the action (s)?

11. P - Physical Drugs Disease Delirium – 30% mortality if undetected
Anticholinergics, benzos,
Include OTC, alcohol
Disease
Atypical presentations, hypoxia, pain, infections
Delirium – 30% mortality if undetected
Hypoactive and hyperactive
Basics
Hydration, bowels, bladder, fatigue, sleep

12. Delirium I – infectious W - withdrawal
A – acute metabolic, dehydration, renal, bowels
T –toxins, drugs
C – CNS pathology
H – hypoxia,
D - deficiencies
E - endocrine
A – acute vascular
T - trauma
H – heavy metals

13. Delirium work up and intervention
History and physical
Bowel/bladder/pain/mobility
Caregivers re what has changed
Review medications including prns
Investigations to identify and correct underlying causes:
Vitals, O2 sat, glucose, chest X-ray
CBC, Na, K, Creatinine, Albumin, Drug levels, Ca, Mg, TSH, B12, Folate, Urine, etc….
CT head if warranted

14. Intellectual/cognitive changes
Memory loss, Amnesia:
Annoying repetitive questioning.
Accusing others of not telling them about upcoming events.
Being “uncooperative” with previous requests.
Agnosia
Accusing family member of being an imposter when cannot quite recognize face…
Failing to recognize one’s image in the mirror.
Utilizing objects inappropriately.

15. Intellectual/cognitive changes
Apraxia
Dressing inappropriately—upset with assistance provided/required
Needing assistance to eat
Aphasia
Frustration/anxiety
Inappropriate requests/comments
Reacting concretely to abstract concept

16. Intellectual/cognitive changes
Anosognosia
Not recognizing that one is no longer knows about or how to do some things, being unaware of deficits and need for help
Impaired executive functions:
poor planning/initiation
unable to appreciate consequences of things said or done before saying/doing them, impulsive behavior
Return to a place back in time

17. Intellectual/cognitive changes
Perceptual difficulties (distances, depth, time elapsed, gaps)
Resisting a bath or toileting, running over others.
Apathy and “perseveration”
May be confused with depression or “ill-will”.
Return of primitive reflexes, perseverative behaviors
Grabbing caregiver’s clothing or body part and being unable to let go.

18. E - Emotions Delusions/Hallucinations/agitation
Dopamine and cholinergic mediated
Depression/irritability/anxiety
Serotonergic, adrenergic, cholinergic mediated.
Adjustment Disorder
Reactivation of past psychiatric illness with stress of dementia, placement
Emotional Memory, past trauma, losses

19. C - Capabilities Balance of Physical Demands and Capabilities
Capacities too low to do a task?
Resistive behaviours, Frustration
Catastrophic reactions
Withdrawal
Able to do more but assumed incapable
Boredom, “attention-seeking” behaviors
Be sensitive to changes in function
Acute change – rule out reversible component
Gradual change – Adapt care to progression of dementia

20. E - Environment Environmental structure Ambience Familiarity
design, lighting (glare), physical space, temperature
Ambience
Sounds, smells, colour, noise
Familiarity
Noise – excessive, distressing, confusing, unfamiliar
Over/under stimulation
Changing environment
Relocation, routines, caregivers

21. S - Social Life story, life accomplishments Social network
‘All about me’, personhood
Social network
Relationships of family
Lifelong coping strategies
Interactions with caregivers who may not know you as a person
Interaction with other residents, roommates, others with dementia…

22. P.I.E.C.E.S. tools Daily Observation Sheet (DOS), A-B-C charting
Shows frequency, severity, patterns of behaviours, can be individualized
Cohen Mansfield Agitation Inventory (CMAI)
Identifies behaviours and severity over 7 day period
Confusion Assessment Method (CAM)
Delirium screen
MMSE, MOCA, Clock
Sig: E Caps, Cornell Depression Scale

23. DOS Behavior Map Time MON TUE WED THU FRI SAT SUN 6am 7am 8am 9am 10a
1pm
2pm
3pm
4pm

24. Other Common Tools Scale Assessment CMAI NPI-NH BEHAVE-AD
The Cohen-Mansfield Agitation Inventory
29 agitated behaviors rated by caregiver on 7 point frequency scale
NPI-NH
Neuro-psychiatric Inventory-Nursing Home Version
12 items rated by caregiver on a 4 point frequency and a 3 point severity scale
BEHAVE-AD
The Behavioral Pathology in Alzheimer’s Disease Rating Scale
25 symptoms rated by caregiver on a 4 point severity scale

25. Caregiver Scales Useful for patients in the community
Self report can be used in office setting or home visit
Allow caregivers to identify behaviours they may not be comfortable talking about in front of their loved one
ie - Kingston Behavioural Assessment

26. Pharmacological treatment
Clear indication, potential benefits
Expected time to response
Risks associated with and without Rx
Appropriate dose range
Monitoring for side effects and response
When to consider dose reduction, discontinuation.

27. Top Ten Behaviors not (usually) responsive to medication
Aimless wandering
Inappropriate urination /defecation
Inappropriate dressing /undressing
Annoying perseverative activities
Vocally repetitious behavior
Hiding/hoarding
Pushing wheelchair bound co-patient
Eating in-edibles
Inappropriate isolation
Tugging at/ removal of restraints

28. Top Ten Behaviors responsive (perhaps!) to medication
Physical aggression
Verbal aggression
Anxious, restless
Sadness, crying, anorexia
Withdrawn, apathetic
Sleep disturbance
Wandering with agitation/aggression
Vocally repetitious behavior
Delusions and hallucinations
Sexually inappropriate behavior with agitation

29. Pharmacological treatment: When (indications)
Behaviors that have not responded to non-pharmacological treatment.
Persistent despite P.I.E.C.E.S. approach
Imminent and severe risk to self or others
E.g. delirium needing to be investigated
Behaviors that can respond to medication: listed previously
Target appropriate symptom cluster: depression, anxiety (acute or chronic), difficulty falling asleep, psychosis…

30. Pharmacological treatment: Choosing best drug
Correct underlying cause, deficiency:
Optimize treatment of dementia, CEIs, memantine
Target appropriate symptom cluster:
Depression: Antidepressant
Anxiety (longer term): antidepressant
Difficulty falling asleep: Trazodone
Psychosis: antipsychotic
Aggression: antipsychotic
Choose least likely to worsen dementia and medical problems
E.g. Least anticholinergic
Choose drugs without problematic interaction

31. Best choices: antidepressants
SSRI for depression or anxiety
Citalopram (Celexa) and Escitalopram (Cipralex)
Sertraline (Zoloft)
When noradrenergic properties may be wanted (pain, activation)
Venlafaxine (Effexor XR) *not if unstable BP
Bupropion (not if unstable BP)
When sedation may be needed urgently
Trazodone *watch for hypotension
Mirtazapine (some anticholinergic properties)
When important to have a drug well tolerated
Moclobemide (Manerix) * drug interactions

32. Best Choices - anxiety Cholinesterase inhibitor SSRIs
particularly for anxiety of early dementia.
SSRIs
first line treatment for anxiety disorders
will take a few weeks to work
check drug interactions.
Consider trazodone (watch for hypotension)

33. Best choices: anti-psychotics
For acute delirium– very short term (days)
Haloperidol (0.5 mg that may be repeated)
Loxapine (2.5 mg that may be repeated)
For persistent psychosis/agitation
Risperidone (Risperdal): start with mg daily and increase slowly as needed/tolerated over weeks to max. 2 mg per day
Olanzapine (Zyprexa): start with 2.5 mg daily and increase slowly as needed/tolerated over weeks, to max 10 mg daily
Quetiapine (Seroquel): start with 12.5 mg daily or BID and increase slowly over weeks to max 200 mg daily

34. Meds for BPSD Target Symptoms Medication Starting Dose
(mg/day)
Average Target Dose
Delusions
Hallucination
Aggression
“Agitation”
Atypical Antipsychotics:
risperidone
olanzapine
quetiapine
2.5-5
50-400
Sadness
Irritability
Anxiety
Insomnia
Antidepressants
citalopram
sertraline
venlafaxine
mirtazapine
trazodone 10 25
37.5
7.5
10-40
50-100
15-45

35. Meds for BPSD Target symptoms Medication Starting Dose (mg/day)
Average Target Dose (mg/day)
Mood swings
Euphoria
Impulsivity
Mood stabilizers:
valproic acid
carbamazepine
250
50-100
Agitation
Apathy
Irritability
Cholinesterase
Inhibitors.
Memantine
As directed
5 mg daily
10 mg BID
Anxiety (short term use in predictable situations)
Anxiolytics:
lorazepam
oxazepam
5-10
10-30

36. Risks present when there is no pharmacological Rx
Risks of injury (self and others), exhaustion, severe and prolonged suffering, increased risk of death with depression, etc.
Need to present the risks of not treating with medications to pt or SDM when obtaining informed consent.

37. Risks associated with pharmacological Rx
Risks of antidepressants:
Hyponatremia
Increased agitation/insomnia/suicide in first few weeks
GI upset and bleed if previous ulcers
Headaches
Risks of anti-psychotics
Increase risk of death (all antipsychotics), increased QT, cerebrovascular accident
EPS and tardive dyskinesia
Worsening of vascular risk factors (increased weight, lipids, diabetes)
Risks of benzodiazepines:
Falls, ataxia, worsening dementia, memory, disinhibition

38. Using minimal effective dose, only for the duration required
Consider dose reduction for antipsychotic as soon as there is clear therapeutic response to prevent development of side effects
Review anti-psychotic medication for possible discontinuation Q 6 months
Maintain full dose of antidepressant but review if still needed after 1-2 years? Only if no prior history of depression

39. Family physicians are at the core of the treatment team, working with:
Patients and substitute decision makers
Other caregivers (home care, LTC staff)
Community resources (Alzheimer Society, First Link programs)
Consultants such as PRCs, Outreach teams, Specialized geriatric medicine and mental health services

40. Questions and further readings
Program for physicians should be available in the coming months: distribution strategies?
CCSMH guidelines on LTC issues, depression, delirium and suicide
New Canadian Consensus guidelines on Dementia.