Best practice in the management of behavioural and psychological symptoms of dementia

Behavioural and psychological symptoms of dementia (BPSD) occur in most patients with dementia. They cause great suffering in patients and caregivers, sometimes more so than the cognitive and functional decline inherent to dementia. The clinical features of BPSD include a wide variety of affective, psychotic and behavioural symptoms and signs. The causes and risk factors for BPSD are multiple and include biological, psychological and environmental variables. Frequently, their combination, rather than any specific factor, explains the occurrence of BPSD in an individual patient. Thus, a sound etiopathogenetic investigation including the patient and the family or care team is essential. The aim is to develop an individualized treatment plan using a therapeutic decision tree modified by the individual and environmental risk profile. Still, treatment may be difficult and challenging. Clinical empiricism often steps in where evidence from controlled studies is lacking. Psychosocial treatment approaches are pivotal for successful treatment of BPSD. Often a combination of different non-pharmacological approaches precedes drug treatment (most of which is off-label). Regular assessments of the treatment plan and any prescriptions must be carried out to detect signs of relapse and to stop any medicines that may have become inappropriate. Even with optimal management, BPSD will not disappear completely in some cases and will remain challenging for all involved parties. This article is a narrative review based closely on the interprofessional Swiss recommendations for the treatment of BPSD. To establish the recommendations, a thorough research of the literature has been carried out. Evidence-based data were provided through searches of Medline, Embase, ISI and Cochrane-Database research. Evidence categories of the World Federation of Biological Societies were used. Additionally, the clinical experience of Swiss medical experts was considered

Colour vision deficiencies in Alzheimer's disease

Objective: visual disorders are among the earliest symptoms of Alzheimer's disease. It is, however, still controversial as to whether Alzheimer's disease impairs colour vision. In this study, colour vision of Alzheimer's disease patients was tested using the Ishihara test and the PV‐16 choice test. The latter test, primarily designed for children, was chosen in order to avoid problems due to cognitive decline. Methods: 26 patients with mild to severe Alzheimer's disease (M:F=5:21; mean age: 80±9 years, range: 53-95 years) and 25 controls (M:F=5:20; mean age 80±10 years, range: 56-100 years) were rated after undergoing complete neuro‐ophthalmologic examination. Results: the Alzheimer's disease patients made significantly more unspecific errors in the Ishihara test (P=0.02) and in the PV‐16 choice test (P=0.0008) than the controls. No relation between test performance and severity of Alzheimer's disease was found. Conclusions: Alzheimer's disease patients have an unspecific colour vision deficiency independent of the severity of the diseas

Behaviorale und psychologische Symptome der Demenz (BPSD): Was tun?

The prevalence of the behavioral and psychological symptoms of dementia (BPSD) is very high in dementia patients. Alterations in multiple neurotransmitter systems are involved in the pathogenesis of BPSD. These symptoms complicate the therapy and outcome. Because of multimorbidity and polpharmacy the therapy of BPSD is difficult and needs continuous clinical observation of the patients. Non-pharmacological interventions must be the first choice of therapy before medication and may accompany the pharmacological treatment. Several non-pharmacological interventions are available and summarized in the following therapy recommendations of the Swiss medical societies. Pharmacological interventions are often accompanied by severe adverse events in dementia patients. Their use must be limited in time and quantity. A critical survey of pharmacological therapy options in dementia is necessary

Compulsory Psychiatric Admission in a Patient With Metastatic Breast Cancer: From Palliative Care to Assisted Suicide

The provision of palliative care in psychiatry and the use of coercion in palliative care are underexplored areas. We report the case of a 65-year-old woman with cerebral metastatic breast cancer who was compulsorily admitted from a specialized palliative care ward to a psychiatric inpatient ward in Zurich, Switzerland. While in specialized inpatient palliative care, the patient had resisted palliative care but was found to lack decision-making capacity for her treatment due to disordered thought process and paranoid delusions. Under our care, which involved coercive treatment in the form of concealed administration of an antipsychotic, the patient's psychiatric symptoms improved. She regained decision-making capacity, was granted discharge from hospital, and ended her life by assisted suicide on the day of discharge

Quality of the caregiving relationship and quality of life in mild Alzheimer's dementia

BACKGROUND: The present study aims to investigate the quality of the dyadic relationship between mild Alzheimer patients and their caregivers. The main objective is to evaluate the consistency, agreement and validity of the German version of the Scale for Quality of the Current Relationship in Caregiving (SQCRC). The secondary objective was to examine the association of relationship quality with quality of life (QOL) in patients with mild Alzheimer's disease (AD) and their caregivers. METHODS: In this study, a sample of 50 patients diagnosed with mild AD and their primary caregivers were included. Participants underwent a full neuropsychological evaluation. The quality of the relationship between persons with AD and their caregivers was assessed using the SQCRC. Furthermore, other scales of relationship quality, well-being of the person with AD, and well-being of the caregiver were used. RESULTS: The results showed that the SQCRC has a good internal consistency and high validity. Also, relationship quality as rated by the AD patients (r = 0.37, P < 0.1) and their caregivers (r = 0.51, P < 0.1) was significantly correlated with QOL. CONCLUSIONS: The findings suggest that many persons with mild AD can rate their relationship quality and that the patient's self-rated relationship quality is a substantial predictor of their QOL

Cognitive behavioural treatment for mild Alzheimer's patients and their caregivers (CBTAC): study protocol for a randomized controlled trial

BACKGROUND About 90 % of all persons with mild Alzheimer's disease experience neuropsychiatric symptoms, most frequently apathy, depression, anxiety and irritability. These symptoms are associated with greater morbidity, a reduced quality of life for the patient, an increased burden and depression for the caregiver, and higher costs of care and nursing home placement. Psychosocial interventions based on behaviour therapy represent the most efficacious treatment of neuropsychiatric symptoms. However, there is no study, to our knowledge, that has evaluated a multicomponent treatment programme based on comprehensive, cognitive behavioural therapy (CBT). This randomized controlled trial aims to evaluate a CBT-based treatment programme consisting of 8 modules and 25 sessions. METHODS/DESIGN Fifty patients with mild Alzheimer's disease alone or with mild mixed dementia (Alzheimer's disease and vascular dementia) who have any neuropsychiatric symptom will be included. A caregiver must be available. The patients and their caregivers will be randomized to either the CBT-based intervention group or to the control condition group, which receives treatment as usual. The primary outcome measure is depression in the patient with Alzheimer's disease. The secondary outcome measures for a person with Alzheimer's disease are other neuropsychiatric symptoms, quality of life and coping strategies. The secondary outcome measures for a caregiver are caregiver's burden, depression, anxiety, anger, quality of life and coping strategies. Neuropsychological testing includes tests of cognitive function and activities of daily living and a global clinical assessment of severity. Participants in both groups will be assessed before and after the treatment phase (lasting approximately 9 months). Follow-up assessments will take place 6 and 12 months after treatment. All assessments will be conducted by blinded assessors. DISCUSSION This trial has the potential to establish an empirically based psychological treatment for non-cognitive symptoms that reduce the quality of life of a person with dementia and a caregiver. This treatment approach focuses not only on the person with dementia, but also on the caregiver and on the dyad. The treatment manual will be published and training workshops will be offered, so that the information can be widely spread among healthcare professionals. TRIAL REGISTRATION ClinicalTrials.gov NCT01273272

Depression über die Lebensspanne: Eine Modellerkrankung mit geschlechtsspezifischer Relevanz

Frauen leiden nach der Pubertät zweimal häufiger unter Depressionen als Männer. Ob dieses Ungleichgewicht real ist oder das «männliche» Depressionssyndrom bisher unzureichend erkannt wird, ist unklar. Biomarker könnten helfen, diese diagnostische Lücke bereits hausärztlich zu schliessen und dadurch auch das depressionsassoziierte Demenzrisiko zu senken

Benzodiazepines and/or neuroleptics for the treatment of delirium in palliative care?-a critical appraisal of recent randomized controlled trials.

Delirium is a frequent condition in patients in a palliative care situation and most often associated with substantial burden or even danger for the persons concerned as well as caregivers and health-care-professionals. Despite the lack of randomized-controlled-trials (RCTs) benzodiazepines and neuroleptic agents are used extensively in palliative care for the pharmacological management of delirium. A focused review for RCTs assessing pharmacotherapy with benzodiazepines and neuroleptics for the treatment of delirium in patients treated in a palliative care or hospice setting published in 2017 was performed in PubMed. A narrative summary of the findings of the RCTs and practical recommendation are presented. Of 42 publications, two RCTs could be included. One trial assessed the use of lorazepam (in addition to haloperidol) in case of agitation, the other placebo or risperidone or haloperidol in delirious palliative care patients. Neither risperidone nor haloperidol were superior compared to placebo, but were associated with higher mortality and morbidity. Lorazepam (along with haloperidol) reduced agitation in patients with delirium compared to placebo (along with haloperidol), but was unable to reduce the severity and incidence of delirium. It is of importance to note that psychopharmacotherapy with antipsychotics is mainly indicated for the hyperactive form of delirium and psychotic symptoms (e.g., delusions or hallucinations) in the hyper- and hypoactive delirium. Severe agitation and aggressivity can be an indication for neuroleptics, when non-pharmacological interventions fail, whereas the use of benzodiazepines has to be limited to critical situations where neuroleptics cannot be applied and cases of delirium due to alcohol withdrawal. Both substances can aggravate, precipitate or mask delirium, result adverse events with substantial distress or unfavorable survival outcomes for the patients. Thus, they should only be used in severely symptomatic patients and the duration of the medication has to be limited in time. When delirium symptoms decay the psychopharmacotherapy has to be tapered. More important than psychopharmacotherapy, the thorough investigation and treatment of potentially reversible causes of delirium (e.g., pharmacotherapy, infection) and the routine identification of patients at risk for delirium along with prophylactic measures are essential. The recently published landmarks RCTs provide moderate evidence to adopt recommendations from other medical specialties (i.e., intensive care, geriatrics) to the field of palliative care