Treating Behavioral and Psychological Symptoms of Dementia (BPSD)

1. Treating Behavioral and Psychological Symptoms of Dementia (BPSD) Kuang-Yang Hsieh, M.D. ph.D. Department of Psychiatry Chimei Medical Center

2. 60 % 20 % (FTD) (DLB) (PD)

4. Role of neurologist and psychiatrist in the course of dementia Neurologist: Identification and correction of risk factors; Early diagnosis and intervention Psychiatrist: Early diagnosis and intervention; Treating BPSD Mild Cognitive Impairment Dementia

8. Treatment of BPSD • Use non-pharmacological treatment first. • Use of psychiatric medication is not routinely recommended unless the problem is severe . In patients with BPSD, the mortality rate was 1.6–1.7-fold higher in the antipsychotics-treated group than in the placebo-treated group.

12. Points for attention about pharmacotherapy of BPSD • Sedative and anticholinergic effects of medications may impede cognitive functions. • Patients with PD or DLB are especially sensitive to extrapyramidal symptoms. • Start low and go slow. • Be careful of the motor, cognitive, metabolic and vascular effects of medications.Beware of the risk of falls. • Assess risk and benefit.

13. Cholinesterase inhibitors and memantine are helpful for BPSD.

14. Antipsychotics are effective for delusion, hallucination, agitation and aggression. • Second-generation antipsychotics are recommended. (Risperdal, Zyprexa, Clozaril, SoLian, Abilify) • Beware of EPS, orthostatic hypotension and metabolic adverse effects.

15. Anticonvulsants are not helpful for BPSD. • If there is significant poststroke or posttraumatic epilepsy, choose an anticonvulsant with less cognitive adverse effects. • Depakine (valproate) and Lamictal (lamotrigine) are recommended.

16. Antidepressants are effective for depression and anxiety • Tricyclic antidepressants (TCAs) • Selective serotonin reuptake inhibitors (SSRIs) • Serotonin and norepinephrine reuptake inhibitors (SNRIs) • Norepinephrine and specific serotonin antidepressant (NaSSA) • Norepinephrine and dopamine reuptake inhibitor (NDRI) • Other serotonin modulators

17. Tricyclic antidepressants (TCAs) • Example: Sinequan (doxepin), Tofranil (imipramine), Deanxit (melitracen) • Inhibiting the reuptake of norepinephrine and serotonin; blocking histamine (H1), alpha1-adrenergic and muscarinic receptors. • Effective for neurogenic pain at low doses.

18. Tricyclic antidepressants (TCAs) • Prominent side effects due to receptor blocking (sedation, hypotension, blurred vision, constipation, urinary retention, dry mouth, exacerbation of glaucoma, cognitive impairment). • Overdose may be lethal, with cardiovascular and CNS toxicity. • Not recommended for BPSD.

19. Selective serotonin reuptake inhibitors (SSRIs) • Example: Prozac (fluoxetine), Zoloft (sertraline) • Being more safe, causing less side effects than TCAs. • Inhibiting cytochrome P450 enzymes, thus increasing the concentration of co-administered medication. • Side effects: insomnia, sexual dysfunction, nausea/vomiting. (through 5-HT1, 5-HT2, 5-HT3 receptor signaling respectively) • Effective for disinhibition, impulsivity and repetitive behavior in FTD.

20. Serotonin and norepinephrine reuptake inhibitors (SNRIs) • Example: Efexor (venlafaxine), Cymbalta (duloxetine) • More effective for pain and anxiety symptoms than SSRIs. • Side effects: insomnia, sexual dysfunction, nausea/vomiting.

21. Norepinephrine and specific serotonin antidepressant (NaSSA) • Example: Remeron (mirtazapine) • Indirectly increasing synaptic norepinephrine and serotonin through blockade of central presynaptic alpha2-adrenergic receptors. • Blocking histamine (H1), 5-HT2 and 5-HT3 receptors. • Causing less insomnia, sexual dysfunction, nausea/vomiting than SSRIs. • Effective for pain, insomnia and anorexia/cachexia. • Side effects: sedation, increased appetite, weight gain.

22. Norepinephrine and dopamine reuptake inhibitor (NDRI) • Example: Wellbutrin (bupropion) • Effective for fatigue, loss of energy. • Causing less sexual dysfunction than SSRIs; may improve sexual dysfunction associated with chemotherapy and hormonal therapy. • Additional benefit for smoking cessation. • Side effects: insomnia, tachycardia, seizure.

23. Other serotonin modulators • Example: Mesyrel (trazodone) • Inhibiting serotonin reuptake; blocking histamine (H1) and alpha1-adrenergic receptors. • Usually used as a hypnotic (10-100 mg/d) rather than an antidepressant (200-400 mg/d). • Decreasing number of awakenings, increasing total sleep time and percentage of deep sleep (stages 3+4). • Side effects: sedation, hypotension, dizziness.

24. Pharmacotherapy for insomnia • Mesyrel (trazodone) is the drug of choice. • Be careful of sedative and muscle-relaxing effects of benzodiazepines. Avoid using them in patients with BPSD.

25. Conclusion • BPSD should be appropriately treated. • Consider Non-pharmacological treatment first. Reserve pharmacotherapy for the second line. • Medication for each patient should be individually taylored. Risk and benefit should be carefully assessed. • Consult the psychiatrist when the problem becomes obvious and out of control.

26. Thank you for attention