Behavioral and Psychological Symptoms of Dementia and Bipolar Spectrum Disorders: Review of the Evidence of a Relationship and Treatment Implications

Abstract

Dementia is a neuropsychiatric disorder characterized by cognitive impairment and behavioral disturbances. The behavioral and psychological symptoms of dementia (BPSD) are common, contributing to caregiver burden and premature institutionalization. Management of BPSD is complex and often needs recourse to psychotropic drugs. Though widely prescribed, there is a lack of consensus concerning their use, and serious side effects are frequent. This is particularly the case with antidepressant treatment based on the assumption that BPSD is depressive in nature. A better understanding of BPSD etiology could lead to better management strategies. We submit that some BPSD could be the consequence of both dementia and an undiagnosed comorbid bipolar spectrum disorder, or a pre-existing bipolar diathesis pathoplastically altering the clinical expression of dementia. The existence of such a relationship is based on clinical observation, as far as the high frequency of bipolar spectrum disorders in the general population, with a prevalence estimated to be between 5.4% and 8.3%, and the psychopathological similarities between BPSD and mood disorder episodes in bipolar illness. We will review the concept of the bipolar spectrum and explain BPSD before proposing clinical pointers of a possible bipolar spectrum contaminating the phenomenology of dementia, which could lead to the targeted prescription of mood-stabilizing agents in lieu of antidepressant monotherapy. These considerations are of heuristic interest in reconceptualizing the origin of the behavioral manifestations of dementia, with important implications for geriatric practice.

Relationship with Bipolar Temperament and Behavioral and Psychological Symptoms of Dementia in Alzheimer’s Disease

“…As for BT, our report is consist with those commented that there were several commonalities in pathophysiological processes of bipolar disorders by Ng et al [4] and that some BPSD could be the consequence of both dementia and an undiagnosed comorbid bipolar disorder, or pre-existing bipolar diathesis pathoplastically altering the clinical expression of dementia by Dorey et al [5]. Moreover, our previous reports those showed the mood cluster becomes connected to the psychiatric cluster and aggressiveness according to that the patients with AD become older and AD progresses.…”

“…Moreover, these features were related with bipolar features, i.e., bipolar temperament (BT), bipolarity or bipolar spectrum. In fact, Ng et al [4] and Dorey et al [5] commented that BPSD was related with bipolar disorder. If so, some kinds of BPSD were treatable because BPSD caused by bipolarity that was not be related with direct AD pathology might be possible to be ameliorated by treatment.…”

Use of atypical antipsychotics in the elderly: a clinical review

“…Behavioral and psychological symptoms of dementia may be both the consequence of cognitive impairment and bipolar disorder comorbidity that of an existing bipolar diathesis, which change the clinical expression of dementia 52. Agitation often worsens some types of dementia and atypical antipsychotics are often effective, even if their use is off-label.…”

Bipolar Disorder: Clinical Perspectives and Implications with Cognitive Dysfunction and Dementia

“…are important elements that should be addressed in the history assessment. Premorbid personality described as energetic and prone to hyperactivity [46] and a positive family history of BPD are important associations in patients with comorbid dementia and late-onset BPD [47, 48]. …”

“…Thus, nonspecific behavioural symptoms of dementia can be an expression with an affective episode of a co-morbid undiagnosed BPD, or otherwise to promote the expression of latent bipolarity [46, 47]. For another perspective, a pre-existing BPD undiagnosed can also be postulated as contributing to the symptoms of affective dysregulation of dementia [48]. This is an important perspective to consider as BPD represents approximately 20% of mood disorders in the elderly [49] and 8% of new cases of BPD occur in geriatric patients [50].…”