1. Neuropsychiatric Symptoms of Dementia Dr. Dallas Seitz MD FRCPC Assistant Professor, Department of Psychiatry Queen’s University

2. Objectives 1.) Understand the prevalence and importance of neuropsychiatric symptoms (NPS) of dementia 2.) Review the biological and psychosocial factors associated with the development of NPS 3.) Review the evidence for pharmacological and non-pharmacological treatments for NPS

3. Neuropsychiatric Symptoms Non-cognitive symptoms associated with dementia Also known as Behavioral and Psychological Symptoms of Dementia (BPSD) – International Psychogeriatrics Association 1996 “Signs and symptoms of disturbed perception, thought content, mood, or behavior that frequently occur in patients with dementia” 1 1. Finkel, Int Psychogeriatr, 1996; 8(suppl 3):497-500

4. What are Neuropsychiatric Symptoms? Agitation 2 : – Restlessness – Requests for help or repetitive questioning – Screaming or vocalizations – Hitting, pushing, kicking – Sexually disinhibited behavior  Delusions 1  Hallucinations  Anxiety  Elevated mood  Apathy  Depression  Irritability  Sleep Changes 1. Cummings, Neurology, 1994 2. Cohen-Mansfield, J Geronotol, 1989

5. Clusters of Neuropsychiatric Symptoms Cohen-Mansfield Agitation Inventory (CMAI )1: – Verbal agitation (yelling, repetitive vocalizations) – Non-aggressive physical agitation (restlessness, pacing) – Aggressive physical agitation Neuropsychiatric Inventory (NPI) 2: – Psychotic symptoms (delusions/hallucinations) – Mood/Apathy (depression/apathy/eating/sleep) – Hyperactivity (agitation/irritability/euphoria/disinhibition) 1. Cohen-Mansfield, J Gerontol, 1989 2. Aalten, Dement Geriatr Cogn Disord, 2003

6. Prevalence of NPS Prevalence in Past 30 Days Lyketsos, JAMA, 2002

7. Prevalence of NPS in Long-Term Care 60% of individuals LTC settings have dementia 1 Overall prevalence of NPS: – Median prevalence of any NPS: 78% 1. Seitz, Int Psychogeriatr, 2010 2. Zuidema, J Geriatr Psych Neurol, 2007 Prevalence of NPS 2 : – Psychosis 15 – 30% – Depression: 30 – 50% – Physical agitation: 30% – Aggression: 10 – 20%

8. Persistence of NPS Neuropsychiatric symptoms are often chronic 1,2 – More likely to persist: delusions, depression, aberrant motor behavior – Less likely to persist: hallucinations, disinhibition 1.Steinberg, Int J Geriatr Psychiatry, 2004 2.Aalten, Int J Geriatr Psychiatry, 2005

9. Associations with Stage of Illness Chen, Am J Geriatr Psychiatry, 2000 Percentage of Individuals with Symptoms

10. Impact of Neuropsychiatric Symptoms Increased patient and caregiver distress 1 Increased risk for institutionalization More rapid functional decline Increased risk of mortality Economic costs 1.Bannerjee, J Neurol Neurosurg Psychiatry, 2006

11. Causes of Neuropsychiatric Symptoms Biological Psychological and social

12. Biological Correlates of NPS Neurotransmitter changes in acetylcholine, dopamine, noradrenergic, serotonin and GABA 1 Volume loss in certain brain regions associated with NPS 2,3 Decrease metabolism in frontal and cingulate cortex associated with psychotic symptoms 4 1.Lanari, Mech Aging Develop, 2006 2.Rosen, Brain, 2005 3.Bruen, Brain, 2005 4.Sultzer, Am J Psychiatry, 2003

13. Psychological Theories of NPS Lowered Stress Threshold 1 Learning Theory 2 Unmet needs  Tailored interventions 3 – Verbal agitation – depression, loneliness – Physically non-aggressive agitation - stimulation – Physically aggressive agitation – avoiding discomfort 1.Hall, Arch Psych Nurs, 1987 2.Cohen-Mansfield, Am J Geriatr Psych, 2001 3.Cohen-Mansfield, Am Care Quarterly, 2000

14. Understanding Neuropsychiatric Symptoms Kitwood’s Framework for Personhood in Dementia 1 SD = P + B + H + NI + SP – SD = manifestation of dementia – Personality – previous coping strategies – Biography – other challenges presented in life – Health – sensory impairment – Neuropathological impairment – location, type, severity – Social psychology – environmental effects on sense of safety, value and personal being 1. Kitwood, Int J Geriatr Psychiatry, 1993

15. Management of Neuropsychiatric Symptoms Differential Diagnosis: – Delirium (medication-induced, other causes) – Depression – Pain or discomfort 1. Sink, JAMA, 2005

16. Assessment of NPS Assessment of behaviors – What are the risks associated with the behavior? To patient, caregivers/staff, other individuals – What is the behavior? E.g. using instrument such as CMAI or NPI – What type of dementia does the individual have? – What is the stage of dementia? – What are the goals of care?

17. Assessment ABC Approach – Antecedents to the behavior (i.e. during care) Behavioral charting using Dementia Observation System DOS – Behaviors (what was the behavior?) – Consequences (what was the response to the behavior)

18. General Principles To Managing NPS Non-pharmacological treatments should be used first whenever available Even when NPS are caused by specific etiologies (pain, depression, psychosis) non- pharmacological interventions should be utilized with medications All non-pharmacological interventions work best when tailored to individual needs and background Family and caregivers are key collaborators and need to involved in treatment planning IPA BPSD Guide, Module 5, 2010

19. Non-Pharmacological or Psychosocial Treatments Training caregivers or staff in behavioral management strategies and communication 1,2 Participation in pleasant events Exercise Music Sensory stimulation (e.g. touch, Snoezelen, aromatherapy) Appear to be well-tolerated and not associated with increased risk of mortality 1.Cohen-Mansfield, Am J Geriatr Psychiatry, 2001 2.Livingston, Am J Psychiatry, 2005

20. Limitations of Psychosocial Treatments Modest effects of treatments – Effects size = 0.2 – 0.5 for many interventions Limited access to programs and human resources necessary for implement May required prolonged and sustained implementation for effects Effectiveness for aggression and psychosis may be limited – Agitation, depressive symptoms may be more likely to respond

39. Resources Canadian Coalition for Seniors Mental Health – www.ccsmh.ca Murray Alzheimer Research and Education Program – www.marep.uwaterloo.ca Alzheimer’s Society – www.alzheimer.ca

40. Resources International Psychogeriatric Association BPSD Guides www.ipa-online.org

41. Links to Materials Webinars on Neuropsychiatric Symptoms – Assessment and Nonpharmacological Management – Pharmacological Management Treatment Tool CCSMH Pocket Card www.dalllasseitz.webs.com

42. Acknowledgments Funding: – Canadian Institutes of Health Research: KRS#103345 KAL#114493 – Clinician Scientist Salary Award, Queen’s University

43. Thank you Questions?