Clinical Perception and Treatment Options for Behavioral and Psychological Symptoms of Dementia (BPSD) in Italy

Abstract

BackgroundBehavioral and psychological symptoms of dementia (BPSD) have a high prevalence, and their presence is associated with a severe impact in terms of social costs. However, dedicated clinical tools or biomarkers to detect these symptoms are lacking. Thus, BPSD management in clinical settings is challenging. The aim of this study was to investigate the perception and the treatment strategies for BPSD in Italian centers working in the dementia field.MethodsA multicenter, national survey was developed by BPSD Study Group of the Italian Neurological Society for Dementia (SINDEM). The survey consisted of a semi-structured questionnaire that was e-mailed to SINDEM members, dementia centers part of the national network of memory clinics (Centers for Cognitive Deterioration and Dementia [CDCD]), and clinicians working in dementia care settings. The questions were focused on (1) perceived global frequency and relevance of BPSD; (2) tools used to assess BPSD; (3) pharmacological treatment for psychosis, apathy, agitation, aggression, depression, anxiety, sleep, and nutrition disturbances; (4) non-pharmacological treatments; (5) drugs side effects.ResultsOne-hundred and thirty-six clinicians participated in this study. Seventy-nine participants worked in a CDCD and 57 in other settings. The perceived frequency of BPSD was 74%. BPSD are detected by means of a clinical assessment for 96.3% or a caregiver interview for 97%. For psychosis treatment the first choice was atypical antipsychotics (83.3%), followed by typical antipsychotic (8.9%) and antidepressants (4.8%). For agitation, atypical antipsychotics were the first-choice treatment in 64% of cases and antidepressants in 16.1%. For aggression, the most used drugs were atypical antipsychotics (82.9%). For anxiety, 55.2% use antidepressants, 17.9% use atypical antipsychotics, and 16.9% use benzodiazepines. Interestingly, most of the centers apply non-pharmacological treatments for BPSD. Some differences emerged comparing the responses from CDCD and other care settings.ConclusionThe survey results revealed many differences in BPSD perception, treatment options, and observed side effect according to the clinical setting. This variability can be explained by the absence of clear guidelines, by differences in patients' characteristics, and by clinical practice based on subjective experience. These results suggest that producing guidelines for the pharmacological treatment of BPSD is a major need.

Assessing behavioral and psychological symptoms of dementia: a comprehensive review of current options and future perspectives

“…A few BPSD also have been included in the diagnostic criteria of specific dementias (Rascovsky et al, 2011 ; McKeith et al, 2017 ), and they are already frequently found in the prodromal phases (Pocnet et al, 2015 ; Van der Mussele et al, 2015 ; Wiels et al, 2021 ), sometimes even being the main presenting symptom in the preclinical condition called mild behavioral impairment (MBI) (Creese and Ismail, 2022 ). Various attempts have been made to cluster them into broader categories, such as psychosis, affective syndrome, apathy, mania, and psychomotor syndrome, but a consensus on the topic is lacking (D'antonio et al, 2022 ). Perhaps due to their elusive nature in terms of both definition and rigorous assessment, these non-cognitive symptoms, in spite of their enormous prevalence, have often been overshadowed by the various sets of diagnostic criteria for dementia syndrome, in general, and Alzheimer's disease, in particular, both of which mainly focus on the cognitive aspects of the two conditions (Gottesman and Stern, 2019 ).…”

BPSDiary study protocol: a multi-center randomized controlled trial to compare the efficacy of a BPSD diary vs. standard care in reducing caregiver's burden

“…The behavioral and psychological symptoms of dementia (BPSD) are a heterogeneous set of psychological reactions, psychiatric symptoms, and behavioral abnormalities that are present in persons with dementia (PwD) due to any etiology (D'antonio et al, 2022 ). These have been grouped in different clusters across different studies.…”

“…One of the most common classifications divides them into five clusters: psychosis (delusions and hallucinations), affective symptoms (anxiety and depression), apathy, psychomotor symptoms (irritability, aberrant motor behaviors, agitation), and mania (euphoria and disinhibition). In Italy, the most common BPSD seem to be agitation, apathy, depression, psychosis, and aggression (D'antonio et al, 2022 ). It is likely that cultural and ethnic differences might partially explain the heterogeneity and relevance of BPSD across different countries and settings, as well as caregivers' responses (Abe et al, 2015 ).…”

“…More than sixty scales and tools have been developed, the most commonly used probably being the Neuropsychiatric Inventory (NPI); however, none of them seems to satisfactorily address all relevant aspects of BPSD (Pozzi et al, 2023 ). Most instruments are limited by the high degree of recall bias, lack of direct observation, and length (D'antonio et al, 2022 ). Finally, an intrinsic risk using broad tools such as the NPI is the imprecise evaluation of BPSD as a unitary construct, aggregating symptoms with different biological basis and treatments (Cho et al, 2021 ).…”

“…Current guidelines suggest to address proximal factors with non-pharmacological strategies as a first line treatment (Calsolaro et al, 2021 ). In practice, psychotropic medication are still largely used, possibly with the exception of BPSD pertaining to eating and sleeping (D'antonio et al, 2022 ). However, antipsychotics have several side effects (D'antonio et al, 2022 ), and despite FDA and European Medicine Agency black-box warnings they are often used for long periods, with an increasing risk of parkinsonism, sedation, falls, stroke, cognitive decline and death (Calsolaro et al, 2021 ).…”