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Behavioural and Psychological changes in dementia

Understandably, when we think of dementia, we tend to focus on the decline in memory and other area of thinking that underpin it. Dementia in all its forms can cause other types of symptoms, however. These include physical changes but also psychological and behavioural changes

The acronym BPSD stands for behavioural and psychological symptoms of dementia and these are often the most distressing aspect of dementia – both for the person affected and those involved in their care. They occur frequently and are often the reason that someone is no longer able to be cared for at home.

Behavioural symptoms include aggression and agitation, apathy, loud vocalisations/calling out, wandering, hoarding and sleep disturbance. Psychological symptoms include anxiety, depression and psychotic symptoms such as delusions and hallucinations. They vary from person to person and also vary according to how severe the underlying dementia has become. Many believe for instance that anxiety may be more common in the early stages.

The treatment of BPSD can be quite varied, though a universal principle that applies to all types of treatment is patient or patient-centred care. This recognises that each person is unique, and it is better to tailor a treatment with this in mind rather than have a blanket approach to a certain type of symptom.

One helpful way of thinking about BPSD is through a model known as the unmet needs model. This considers that the behavioural or psychological symptom is a manifestation of a problem that the person exhibiting it is unable to express due to their cognitive or language problems. Examples might include agitation that arises due to the need to open your bowels, or sleep disturbance due to pain. The more you know about a person, the easier it will be to come up with a solution.

Another important element of care is to start with measures that don’t involve medications if possible. Medications can have significant side effects, especially in someone whose brain is already vulnerable due to dementia and should be reserved for situations where other measures have failed, or where there is an imminent risk of aggression.

My own experience with BPSD, however, is that medications can be very helpful and well tolerated, though their use should target specific symptoms if possible (e.g., using an antidepressant if there are signs of depression). Doses should start off low, and only be increased if need be. BPSD can also spontaneously settle with time (even though the dementia may be getting worse). This means that it is good practice to try and withdraw these medications periodically.

More information on this important topic can be found in my book, Mind Your Brain.

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© 2021 Dr Kailas Roberts

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