SELAMAT MENGIKUTI KULIAH

BPSD

BPSD

A.INTRODUCTION
With the aging of the worlds population, a significant increase in the absolute num-ber of elderly with Alzheimers disease (AD) and other irreversibly dementias is now taking place

BPSD

Dementia is associated with progres-sive cognitive disability, a high prevalence of Behavioral and Psychological Symtoms of Dementia (BPSD) such as agitation, depression and psychosis, stress in caregivers and costly care.

BPSD

BPSD Introduction to Behavioral and Psychological Symptoms of Dementia

What does "BPSD" mean? "BPSD" stands for behavioral and psychological symptoms of dementia, a phrase coined by participants at an international consensus conference on behavioral disturbances of dementia convened by the IPA

BPSD

What are BPSD? The Behavioral And Psychological Symptoms of Dementia are defined as:
"Symptoms of disturbed perception, thought content, mood, behavior frequently occurring in patients with dementia".

Symptoms assessed at patient/relative interview

Symptoms assessed by behavioral observation or by patient/relative: Anxiety, Aggression, Depressed mood, Screaming, Hallucinations, Restlessness. Delusions, Agitation, Wandering, Culturally-inappropriate behaviors, Sexual disinhibition, Hoarding ,Cursing, Shadowing.

BPSD

Definition
1.Behavioral and Psychological Symtoms of Dementia (BPSD): Symtoms of: -disturbed perception, -thought content, -mood or behavior that frequently occur in patients with dementia (Finkel and Burns,1999)
2.Aheterogenous range of psychological reaction, psychiatric symtoms and behaviors occuring in people with dementia of any etiology (IPA)

BPSD

The demetias are (e.g.):

Alzheimers disease (AD) Vascular Dementia Lobus Frontotemporal Degeneration Parkinsons Disease Lewy Bodies Dementia Picks Disease Dementia

BPSD

BPSD are an integral part of the disease process and present severe problems to patients, their families, caregivers and society at large

BPSD

BPSD can be grouped in :

Behavioral symtoms:

physical agression, screaming, restlessness, agitation, wandering, culturally inappropiate behaviors sexual disinhibition, hoarding, cursing and shadowing

Psychological symtoms:

anxiety, depressive mood, hallucinations, delusions.

BPSD

How common are BPSD? Approximately 83% of demented patients demonstrate psycho-pathology:
delusions 60% hallucinations, 20% verbal outbursts, 33% anxiety 35% affective symptoms. 40% physical aggression some 13% behavioral problems 64% of nursing home patients The most common BPSD resulting in institutionalization are paranoia and aggressive behavior.

BPSD

The prevalence of BPSD

Sign or Symtoms Perceptual:
Delusions Misidentifiations Hallucinations

%
20-73 23-50 15-49

Affective
Depressions Manics up to 80 3-15
up to 90 up to 50 up to 20

Personality
Personality change Behavioral symtoms Agression / hostility

BPSD

BPSD are treatable and generally respond better to therapy than other symtoms or syndromes of dementia

BPSD

Treatment of BPSD offer the best chance to alleviate suffering, reduce family burden and lower societal cost in patients with dementia

BPSD

B.CLINICAL ISSUES Behavioral and Psychological symtoms of dementia (BPSD) are very common and are significant symtoms of the illness

Among the most intrusive and difficult BPSD to cope with are:

BPSD

Psychological symtoms of:

delusions hallucinations misidentifications depression sleeplesness anxiety Behavioral symtoms of physical aggression wandering restlesssness

BPSD

Moderately common BPSD which can also be distressing include:

agitation culturally inappropriate behavior sexual disinnhibition pacing (jalan bolak balik) screaming

BPSD

BPSD that are common and upsetting, but that are more manageable and less likely to result in institutionalization include:
crying cursing apathy repetitive questioning shadowing (stalking = mengikuti )

BPSD

C.ETIOLOGY There are dementia multiple etiologies for BPS of

Currently, the best model is one that:

-incorporates genetic (receptor polymorphism), -neurobiological aspects(neurochemical, neuropathology) -psychological aspects ( respons to stress), and -social aspects (environmental change and caregiver factors )

BPSD

Functional neuroimaging studies:

BPSD are not random consequenses of difuse brain illness, but are fundamental expression of regional cerebral pathology

BPSD

Disruption of circadian rythms result in BPSD and lead to agitation during the day and restlessness at night. Furthermore abnormalities in circadian rhythm may be responsible for sundown syndrome.

BPSD

The emergence of BPSD and th need for Hospitalization are often associated with antecedent of life events characterized by change in social routine and environment

BPSD

D.ROLE OF CAREGIVERS
Support by caring relatives is a key factor in community care of people with dementia The emotional relationship between the responsible relative and the person with dementia significantly determines wether family care can be maintained

BPSD

An effective care system enables caregiver to continue Caring for their relatives with dementia at home and, at the same time, minimize the negative consequenses to them. The demands of caregiving may not precipitated an illness event per se in the caregivers, but rather may aggravate existing vulnerabilities to ilness

BPSD

Enhancing the skill of the caregivers in interacting with the patient may prolonges the caregivers ability to provide in-home care and improve the quality of live of both Consideration of BPSD, witthout understan-ding the context for the behaviors, can cause staff to view the person with dementia as a collection of symtoms rather as a whole person

BPSD

Caregivers distres and poor interpersonal relations between the patient and the caregiver can exarcebate BPSD Caregivers can provide useful information about antecedents of, and possible reasons for, behavioral This information usually requires more than a single, brief interview Caregivers who have had a poor premorbid relationship with patient are more likely to misinterpret agitated behavior as a purposefully provocative and worsen the situation with an angry retord .

BPSD

E.NON-PHARMACOLOGIC MANAGEMENT
Non-pharmacologic interventions are usually first-line in dealing with milder BPSD in dementia. There is alimited, but faster growing, body of research supporting the use of these interventions, although some of them are based on experience, not evidence Problems without an environmental trigger, are severely distressing to the caregiver, may require medications often (though not always) in conjunction with non-pharmacological interventions

BPSD

Nonpharmacologic therapies may be most useful for patients with mild to moderate dementia who do not have an untreated mental disorder apart from dementia. Knowledge of the patient's premorbid personality and habits can inform the physician's choice of nonpharmacologic therapies.

BPSD

Symtoms that are responsive for non-pharmacological interventions include: -depression /apathy -wandering / pacing pacing -repetitive questioning / mannerisms

The ideal environment for patient with dementia is one that it is non-stressful, constant and familiar

BPSD

A general approach to behavioral interventions include: -identified the target BPSD -gather the informaions on BPSD -identify the trigger or consequential events of a spesific symtom -set realistic goals and make plans -encorage caregivers to a reward for themselves and others for achieving goals Continually evaluate and modify plans

BPSD

Recreational, music and bright-light therapies are interventions that have been shown to reduce anxiety and agitation

For patients with dementia reality orientation and music therapies have the strongest research base although a number of resent studies have begun determine the impact of other therapies

BPSD

Psychological and psychosocial interventions Including psychotherapy (individual, group, and family) when tailord to the individual needs of patiens, families, caregivers can have a significant Impact on patients wellbeing. Such interventions need to be modified, as the individual need change during the course of the illness.

BPSD

F.PHARMACOLOGICAL MANAGEMENT The past decade has seen a substantial increase in nonpharmacologic treatments for behavior disturbances in dementia, including validation therapy, reality orientation, music and movement therapies, and environmental antiwandering programs.

BPSD

In general, non-pharmacological approaches are first line treatment for BPSD of dementia For BPSD that are moderate to severe and impact on the patients or caregivers quality of life or functioning, medication is clearly indicated often in conjunction with non-pharmacological interventions

BPSD

Treatment approaches: drug treatment. When a specific co-existing mental disorder other than the dementia is identified, the appropriate treatment for that disorder is given, e.g. an antipsychotic for frank psychosis or an antidepressant for depressive symptoms.

BPSD

If the patient has symptoms of a mental disorder but does not meet diagnostic criteria for a complete syndrome, appropriate drug treatment may still be indicated if it is likely that the subsyndromal mental disturbance has caused the BPSD.

BPSD

In elderly patients with dementia, dosages of medication will generally be lower than those used in younger patients and in older nondemented persons However, the elderly are a heterogenous group requiring an individualized approach to dosing Antipsychotic medicstion is most effective in the treatment of psychotic symtoms (hallucinations, delusions) and behavior symtoms, such as physical agression

BPSD

Newer antipsychotic medications appear to be at least as effective as conventional neuroleptics, but may have fewer side effects Antidepressant medications are underused in people with dementia, despite the commen occurrence of depresion in dementia and yhe documented the documented therapeutic values of these drugs

BPSD

F.CROSS-CULTURAL AND TRANSNATIONAL CONSIDERATIONS

Studyieng BPSD across culture allows the identification of similarities and differences that may be useful to determine the best approach to managing these symtoms in different populations

BPSD

An effective approach to management in one culture may not necesserly work in another, given the different prevalence of various BPSD and level of tolerance for them within that culture

BPSD

The patients and caregivers location can affect the impact and subsequent of BPSD Symtoms that pose difficulties in an urban setting, such as pacing or wandering may not be regarded as problematic in a rural setting where most of patients will have room to pace and are less vulnerable if they wander

BPSD

Comorbid conditions such as schizofrenia, depression and alcoholism may vary jn frequency acros communities and could alter the presentation of BPSD in demented subjects

BPSD