Behavioral and Psychological
Behavioral and psychological symptoms of dementia (BPSD) form one of the main clinical concepts studied in the field of Alzheimer’s disease (AD), as well as related dementias. Over 90% of patients with dementia experience various forms of “behavior disturbances” (Ballard & O’Brien, 1999, p. 138). BPSD can occur at various periods of time throughout the course of dementia (Herrmann, Lanctot & Khan, 2001). BPSD has become one of the main focuses in the study of AD because its symptoms play a significant role in determining the lifestyle and type of management used with the patients with Alzheimer’s disease. More than 10% of the US individuals over 65 years of age suffer from Alzheimer’s disease (Herrmann, Lanctot & Khan, 2004). Recently BPSD has become a growing public health problem for the population due to the overall aging of the nation (Lyketsos et al, 2002).
There is still no clear identification of the reasons that cause BPSD. Tampi et al (2011) have concluded that both anatomical and biochemical changes in the brain of AD patients lead to the development of the BPSD (p. 2). There is also a theory that BPSD is heritable because some studies prove that within families dementia symptoms can occur more frequently. Lanctot et al (2004) state that the important role in the development of BPSD is played by the disruption of neurotransmitter systems and especially, deficits in the cholinergic system (p. 439).
BPSD can be found in the majority of patients with AD at some point of the disease development. Robert et al (2004) AND Ballard et al (2011) state that around 90% of patients experience various combinations of the BPSD symptoms, while other researchers state that the part of AD patients suffering from BPSD varies from 1/3 (Tampi et al, 2011) to 2/3 (Lawlor, 2002).
The symptoms of BPSD are highly unpredictable and extremely heterogeneous. The variety of symptoms observed by a caregiver or experienced by the patient include disturbance of emotions, mood, mobility, and even altered personality traits (Cerejeira, Lagarto & Mukaetova-Ladinska, 2012). There is no unified set of symptoms, which not only complicates the study of BPSD, but also requires individual approach to treatment and support of each patient with behavioral and psychological symptoms of dementia.
Researchers have developed various approaches to defining the symptoms that together constitute BPSD. Burns, Byrne, Ballard & Holmes (2002) name the following symptoms of dementia: agitation, aggression, depression, delusions, sleep disturbance, hallucination, and wandering (p. 1312). One of the approaches separates these symptoms into two categories: observed behaviors and elicited psychological symptoms (Lawlor, 2002). The main disadvantage of this approach is the confusion caused by some symptoms, which are both “elicited” and “observed behaviors.” Robert et al (2004) propose to group symptoms of BPSD in different categories such as “apathy/mood or agitation/psychosis” (p. 494). Additional classification is named by Shergill (2009), who identifies four groups of symptoms within the complex notion of BPSD: psychosis/apathy, depression/anxiety, persecution/irritability, and wandering/sleep problems (p. A11). The concept of BPSD is a very complex one, thus, those studying this compound disease cannot have a single defined approach to BPSD and methods of treating the symptoms.
In the treatment of BPSD various methods are used in order to decrease the symptoms and reduce their effects on the lives of patients and caregivers. There is no standardized system of medical treatment for BPSD patients. Instead caregivers use individual approaches adjusted to the needs of each single patient. Interventions in BPSD include environmental, psychological, behavioral, and pharmacological treatments. While pharmacological treatments might seem to be the most effective, they are used only to provide short-term results and treat severe conditions. Non-pharmacological treatments, on the other hand, significantly increase the overall condition of BPSD patients.
Burns, Byrne, Ballard & Holmes (2002) emphasize the importance of various medical substances, such as neuroleptics and various sedatives, while Kar (2009) adds to the list of medical substances used for the treatment of BPSD cognitive enhancers, mood stabilizers, and benzodiazepines. Cholinesterase inhibitors can reduce the severity of BPSD and decrease the further need for psychotropic medications (Kar, 2009). According to Tampi et al (2011), pharmacological treatments should target specific clinically significant BPSD symptoms.
Strong medications are usually used for short-term treatments of severe symptoms and do not provide patients and caregivers with the long-term positive results. The disadvantage of drug treatment is also seen through the wide range of side effects, such as sedation, falls, extrapyramidal signs etc. (p. 1312). The use of antipsychotics for the treatment of AD and BPSD has raised such concerns in the United States that in 1987 a special legislation was passed (Lee et al, 2004). Its main aim was to reduce the use of antipsychotic medicine in the US nursing homes. At the same time, at the beginning of the 21st century atypical antipsychotic drugs have become more [popular in treatment of AD and other dementias. Therefore, although pharmacological treatment is currently less popular than the non-pharmacological one, there are still constant developments in the field.
While some scientists emphasize the role of medical substances in the process of BPSD treatment, others focus on non-pharmacological interventions and define them as the main way of treating BPSD (Tampi et al, 2011). Burns, Byrne, Ballard & Holmes (2002) name such alternative treatments as aromatherapy and bright light treatment. (Kar, 2009) identifies a set of various non-pharmacological approaches that have already shown significant results in the treatment of BPSD: modifications of environment, social interactions, prompt medical and nursing interventions, and behavioral interventions. An essential element in providing effective care and non-pharmacological treatment of patients with BPSD is the proper training of medical personnel and caregivers, which should consist of educational program about BPSD and knowledge about better ways to address the needs of patients.
Behavioral and psychological symptoms of dementia significantly complicate the lives of AD patients, as well as create more difficulties for their caregivers. BPSD add considerable difficulties to the treatment of patients both in the healthcare institutions and home environments (Ballard et al, 2000). The symptoms of BPSD are among the main reasons for hospitalization and institualization of patients with Alzheimer’s disease (Tampi et al, 2011). Due to the nature of the disease BPSD patients are hard to work with. Disrupted agitated behaviors can be seen in as much as 90% of the patients; aggression may occur in up to 65% of people with BPSD (Herrmann, Lanctot & Khan, 2004), as well as non-aggressive agitation in 20% of patients (Ballard et al, 2011). BPSD not only lowers the quality of life of the BPSD patients and their caregivers, but also puts a significant physical burden on those providing support to the patients (Cerejeira, Lagarto & Mukaetova-Ladinska, 2012), which leads to the faster transfer of patients to nursing homes.
Taking into consideration the complexity of BPSD, various methods are used to study the disease: behavioral studies; electropsychological, neuropathological, and neurochemical methods (Robert et al, 2004, p. 492); brain imaging etc. There are well-developed tools and scaling systems that can be used in the assessment of BPSD: Apathy Evaluation Scale, Behavioral Rating Scale for Geriatric Patients, Behavioral Rating Scales for Dementia, Cornell Scale for Depression in Dementia and many others (Kar, 2009). Various instruments of behavioral assessment are used to understand the essence of BPSD and possible ways of its management and treatment. Robert et al (2004) not only define the three main approaches of behavioral assessment of the BPSD patients, but also indicate their disadvantages: subjective patient self-evaluation; non-professional family interviews; professional observations without the insight into the patient’s daily life. Further development is required in the field of BPSD scaling. Kar (2009) makes a special emphasis on the creation of cross-cultural methods for the BPSD evaluation, which will be of significant help in the epidemiological studies of the population (p. S80).
BPSD is a significant problem for patients suffering from the Alzheimer’s disease and other dementias. It is quite common among the AD patients, although there is no clear definitions of the reasons that cause BPSD and its varied symptoms. There is no unified set of BPSD manifestations because they vary from patient to patient with various levels of intensity. Although researchers have already proposed various ways of grouping the BPSD symptoms, there is still no possibility to define the course of the disease and its possible development. BPSD influences not only the lives of sick people, but also shape the lifestyle of their caregivers because BPSD patients need special approach and living conditions, as well as constant support and care. The treatment of BPSD is commonly grouped in two categories: pharmacological and non-pharmacological, where the first type is used to treat the strongest symptoms and provides only the short-term results. Behavioral and psychological symptoms of dementia have been in the center of medical attention for the past decades due to their significant influence on the lives of both patient and caregiver. There are still many issues that remain unsolved including proper assessment of BPSD, symptomology, and its treatment.