The problem with "problem behaviors": a systematic review of the association between individual patient behavioral and psychological symptoms and caregiver depression and burden within the dementia patient-caregiver dyad

ABSTRACT Background: Behavioral and psychological symptoms of dementia (BPSDs) are routinely cited as important predictors of caregiver burden and depression. Although BPSDs include a wide variety of patient behaviors, they are routinely grouped together as one construct to differentiate them from cognitive symptoms of dementia. Determining the specific BPSDs that result in increased depression and burden for caregivers may elucidate the stress process for caregivers and facilitate the development of effective interventions for caregivers. Methods: We conducted a systematic review of English-language articles published from 1990 to 2010 to determine whether there are known symptoms or symptom clusters which exert undue negative impact on caregiver depression and burden. Additionally, we review systems used for classifying BSPD symptom clusters and determine whether there have been any mechanisms studied by which individual BPSD symptoms negatively affect caregivers. Finally, we examine how the role of timing of symptoms has been examined within the literature. Results: Thirty-five original research articles examined the impact of an individual behavior symptom on caregiver burden or depression/depressive symptoms. The studies had no consistent system for categorizing symptoms. Although depression, aggression, and sleep disturbances were the most frequently identified patient symptoms to impact negatively on caregivers, a wide range of symptoms was associated with caregiver burden and depression. Conclusions: The evidence is not conclusive as to whether some symptoms are more important than others. The studies reviewed were largely exploratory relative to the differential impact of individual BPSDs and did not focus on testing causal mechanisms by which specific symptoms exert more impact on caregiver mental health than others. Future research may benefit from the re-conceptualization of BPSDs from the perspective of their impact on the caregiver to examine hypothesis-driven differences among BPSD symptom clusters.     

The Comorbidity of ADHD and Bipolar Disorder: Any Less Confusion?

Alzheimer’s disease (AD) is the most common type of dementia and is a significant public health problem that will intensify as the population ages. The behavioral and psychological symptoms of dementia (BPSD) present a significant burden to patients, their families, and their caregivers. The majority of care is provided at home by family caregivers. Caring for a person with AD and other dementias is associated with significant risk to the caregiver’s health and well-being. Healthcare providers must recognize that family caregivers often present as secondary patients. Given the importance of these caregivers to patients with AD and other dementias, it is vital to understand the risk factors that impact caregiver health and well-being. Non-pharmacological interventions can reduce the negative impact of caregiver burden on caregiver health, reduce premature institutionalization of patients, and improve quality of life for patients, their families, and their caregivers. This article summarizes recent relevant research concerning AD and dementia caregiver health and psychosocial interventions.     

Caregiver burden associated with behavioral and psychological symptoms of dementia in elderly people in the local community

BACKGROUND: Despite many studies about the association between caregiver burden and behavioral and psychological symptoms of dementia (BPSD), there have been no population-based studies to evaluate caregiver burden associated with each BPSD. OBJECTIVE: To evaluate caregiver burden associated with the individual BPSD in elderly people living in the community. METHODS: The subjects were 67 participants with dementia living with their caregivers (diagnosed in the third Nakayama study): 51 Alzheimer's disease, 5 vascular dementia and 11 other. The Neuropsychiatric Inventory (NPI) and NPI Caregiver Distress Scale (NPI-D) were used to assess subjects' BPSD and related caregiver distress, respectively. RESULTS: In the subjects exhibiting BPSD, aberrant motor behavior had the highest mean NPI score, and depression/dysphoria had the lowest. Agitation/aggression had the highest mean NPI-D score, and euphoria/elation had the lowest. Delusion, agitation/aggression, apathy/indifference, irritability/lability and aberrant motor behavior showed a correlation between the NPI and NPI-D scores. CONCLUSION: The burden associated with BPSD is different for each symptom and does not always depend on frequency and severity of BPSD. These findings suggest that some symptoms, such as agitation/aggression and irritability/lability, may affect the caregivers significantly, although their frequency and severity are low.     

Do memory clinics improve the quality of life of carers? A randomized pilot trial.

OBJECTIVE: To determine the effects of attendance at a memory clinic on the psychosocial health of carers. DESIGN: Randomized control trial. PARTICIPANTS: Fifty community dwelling subjects with mild to moderate dementia and their carers. MAIN OUTCOME MEASURES: Carer burden, psychological morbidity and psychosocial health related quality of life at 6 and 12 months post intervention. MAIN RESULTS: There was significant improvement in psychosocial health related quality of life of carers as measured by the psychosocial domain of the Functional Limitation Profile (FLP) at 6 months (p < 0.01), including improvement in the subgroups of alertness behaviour (p < 0.05) and social interaction (p < 0.01), after adjustment for age of subject and baseline scores. The improvement in social interaction was maintained at 12 months (p < 0.05). There was no significant difference in carer psychological morbidity (General Health Questionnaire), carer burden (Zarit family interview) or carer knowledge of dementia (Dementia Knowledge Test) at 6 or 12 months, between groups. CONCLUSIONS: These results demonstrate improved psychosocial health related quality of life for carers of those with mild to moderate cognitive impairment attending a memory clinic. Further research in this area is indicated, comparing memory clinic intervention with alternative support.     

Collaborative memory intervention in dementia: Caregiver participation matters

The aim of the study was to examine the effectiveness of a collaborative memory intervention for persons with dementia and their spousal caregivers, where the couple acquired and practised memory supportive strategies (spaced-retrieval and hierarchical cuing) to learn a face–name association and to set a table for coffee/tea. The collaborative intervention was compared to an individual intervention where the person with dementia received the same training but without the participating caregiver and to a control group of couples receiving no training. The results showed that following collaborative intervention recall performance in two collaborative tasks became more equally shared between the spouses, reflected in a decrease in recall for the caregiver and in an increase in recall for the spouse with dementia between pre- and post-test; whereas for the other two groups the caregivers dominated collaborative recall both at pre- and post-test. The results also showed that the persons with dementia in the collaborative group improved their individually assessed episodic memory performance as compared to the persons with dementia in the other two groups. Finally, training had no effects on episodic memory, perceived burden or depressive symptoms for the caregivers. These results suggest that the active participation of the caregiver matters in cognitive dementia rehabilitation.     

Role of serotonin in the behavioral and psychological symptoms of dementia

The behavioral and psychological symptoms of dementia (BPSD) can have serious debilitating effects on the patient and increase caregiver burden. Investigations into the underlying neuropathology indicate that the serotonergic system may contribute to BPSD. In addition, serotonergic pathways are known to interact extensively with the cholinergic, noradrenergic, GABAergic, and dopaminergic systems. Hence, serotonergic therapies may be used to manipulate other neurotransmitters systems to alleviate BPSD or in combination with agents specific for the other neurotransmitter receptor sites. Neurotransmitter-modulated behaviors and evidence provided by pharmacological interventions are reviewed, focusing primarily on the serotonergic system.     

A systematic review of the association between the Behavioral and Psychological Symptoms of Dementia and burden of care

BACKGROUND: Several reports have indicated that the Behavioral and Psychological Symptoms of Dementia (BPSD) are associated with increased burden of care, carer depression and increased rates of institutionalization of patients. The present study aims to review the association between these variables in cross-sectional as well as longitudinal studies. METHODS: Systematic review and meta-analysis of all available information published in English between January 1990 and December 2001 was made. Case-reports, case-series and studies with 20 or fewer subjects were excluded from the analyses. RESULTS: Thirty articles are included in the review of cross-sectional data and 12 in the systematic review of longitudinal data. Pooled correlation coefficients were generated for the relationship between BPSD and caregiver burden (r(pooled) = 0.57; 95% CI = 0.52 to 0.62), caregiver psychological distress (r(pooled) = 0.41; 95% CI = 0.32 to 0.49) and caregiver depression (r(pooled) = 0.30; 95% CI= 0.21 to 0.39), suggesting that these concepts have a moderately strong association. Multivariate data, on the whole, further supported the notion that BPSD are a predictor of burden of care and of psychological distress and depression. Limited longitudinal data made clarifying the temporal relationahip between BPSD and the psychological sequelae of care (PSC) difficult. The limited data pertaining to the relationship between BPSD and institutionalization suggest that caregiver variables may be more important in predicting institutionalization than BPSD. Methodological issues and limitations associated with this type of investigation were also considered. CONCLUSION: The results of this review support, but do not conclusively establish, the association between BPSD and PSC. We propose that the concept of burden of care be abandoned in favor of more clinically relevant outcomes such as caregiver depression.     

Psychiatric morbidity in dementia patients in a neurology-based memory clinic

The behavioral and psychological symptoms of dementia (BPSD) often present major problems for patients and their caregivers. In the past, neurologists paid less attention to such symptoms than to the cognitive symptoms of dementia. This prospective study investigated the prevalence of psychiatric morbidity in a neurology-based memory clinic and the stress of caregivers. Our patients with dementia were found to have a high prevalence of BPSD. The most frequent were anxiety, apathy, and delusion; the most distressing to caregivers were agitation, anxiety, delusion, and sleep disturbance. Using Clinical Dementia Rating (CDR), we compared BPSD between patients with mild dementia and those with moderate dementia. Only hallucinations and agitation were different significantly. Moderate dementia patients experienced these symptoms more frequently. The high prevalence of these symptoms might be explained by the fact that the cognitive symptoms were neglected or no enough information were received by many family members of patients with dementia until their own life quality was interfered and then they began to seek medical help. These symptoms and their effect of caregiver distress can be effectively reduced by pharmacologic and nonpharmacoloic managements, caregiver-focused training and education. They can be better approached by assessing neuropsychiatric symptoms regularly, educating the general population better, and treating these patients earlier.     

Stopping antipsychotic drug therapy in demented nursing home patients: a randomized, placebo-controlled study--the Bergen District Nursing Home Study (BEDNURS)

BACKGROUND: Despite modest efficacy, unpredictable individual utility, and a high rate of adverse effects, behavioural and psychological symptoms of dementia (BPSD) are common determinants for antipsychotic drug therapy in nursing home patients. AIMS: To explore the impact on BPSD of stopping long-term antipsychotic treatment in nursing home patients with dementia. METHODS: Fifty-five patients (43 women; mean age 84.1) taking haloperidol, risperidone, or olanzapine for BPSD were randomly assigned to cessation (intervention group, n = 27) or continued treatment with antipsychotic drugs (reference group, n = 28) for 4 consecutive weeks. The Neuropsychiatric Inventory (NPI) Questionnaire was used to examine changes in behavioural and psychological symptoms. RESULTS: By study completion, 23 of the 27 intervention group patients were still off antipsychotics. Symptom scores (NPI) remained stable or even improved in 42 patients (intervention group, 18 out of 27; reference group, 24 out of 28; p = 0.18). As compared to patients with stable or improved symptom scores, patients with behavioural deterioration after antipsychotic cessation used higher daily drug doses at baseline (p = 0.42). CONCLUSION: A large share of elderly nursing home patients on long-term treatment with antipsychotics for BPSD, do well without this treatment. Standardized symptom evaluations and drug cessation attempts should therefore be undertaken at regular intervals. Copyright (c) 2008 John Wiley & Sons, Ltd.     

Behavioral and psychological signs and symptoms of dementia: a practicing psychiatrist's viewpoint

Alzheimer's disease typically presents with two often overlapping syndromes, one cognitive, the other behavioral. The behavioral syndrome is characterized by psychosis, aggression, depression, anxiety, agitation, and other common if less well-defined symptoms subsumed under the umbrella entity "behavioral and psychological symptoms of dementia" (BPSD), itself divided into a number of subsyndromes: psychosis, circadian rhythm (sleepwake) disturbance, depression, anxiety, and agitation, it is BPSD with its impact on care providers that ultimately precipitates the chain of events resulting in long-term institutional care. The treatment challenge involves eliminating unmet medical needs (undiagnosed hip fracture and asymptomatic urinary tract infection or pneumonia). Pharmacologic intervention relies on risperidone and, increasingly cholinesterase inhibitors for the control of psychosis (but with response rates of only 65% at tolerable doses), olanzapine and risperidone for anxiety, and carbamazepine and valproic acid for agitation. However, evidence increasingly favors nonpharmacologic interventions, to the extent that these should now be considered as the foundation of BPSD treatment. Problem behaviors are viewed as meaningful responses to unmet needs in the therapeutic milieu. Because the progression and impact of BPSD varies between patients, interventions must be explored, designed, implemented, and assessed on an individual basis. They include: family support and education, psychotherapy reality orientation, validation therapy, reminiscence and life review, behavioral interventions, therapeutic activities and creative arts therapies, environmental considerations (including restraint-free facilities), behavioral intensive care units, and workplace design and practices that aid the ongoing management of professional caregiver stress.     

The impact of neuropsychiatric symptoms of dementia on distress in family and professional caregivers in Singapore

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are a source of distress and burden for caregivers. This study attempts to determine the neuropsychiatric symptoms, demographic characteristics, and referral patterns of outpatients with dementia compared with patients admitted to the acute psychogeriatric wards of Woodbridge Hospital. We also assessed the impact of neuropsychiatric symptoms on distress in family and professional caregivers. METHOD: Eighty-five consecutive patients with a first-time diagnosis of dementia were recruited. They were assessed using the Neuropsychiatric Inventory Caregiver Distress Scale (NPI-D). The professional caregiver distress questions were rephrased to assess the "occupational disruptiveness" of behaviors in the nursing home version (NPI-NH). RESULTS: Neuropsychiatric symptoms were common and were positively correlated with caregiver distress. Family caregivers were significantly more distressed than professional caregivers over the delusion, agitation, depression and aberrant motor domains, although the severity of the behavioral disturbances reported was not higher in the sample. The median NPI scores for the agitation and disinhibition domains were significantly higher in the inpatient group, contrasting with a higher score for the depression domain among the outpatient group. CONCLUSIONS: This study highlights the prevalence of neuropsychiatric symptoms in dementia and illustrates the strong correlation between the severity of behavioral disturbances and caregiver distress.     

Behavioral and psychological symptoms of dementia and caregivers' stress appraisals: intra-individual stability and change over short-term observations

Dementia is commonly associated with memory loss, but Behavioral and Psychological Symptoms of Dementia (BPSD) such as disruptive behaviors, agitation, and problems with mood, usually have a more significant impact on caregivers' stress. It is known that BPSD and caregivers' stress reactions vary in frequency over the long-term course of dementia, however little is known about the variability over the short-term. The current study included 85 people with dementia and their primary caregivers assessed over three months. Caregivers used a 24-hour log on multiple, consecutive days to report behavioral symptoms of dementia on seven domains of behavior, as well as their stress reactions for each domain. Using latent growth curve analysis, most BPSD and caregiver stress appraisals were found to be, on average, stable over the three-month time frame. For many BPSD and stress appraisal models, however, intra-individual differences in rate of change were significantly different from the mean trend, indicating behaviors and stress are not stable over three months when assessed at the level of the individual. Covariates were used to explain individual differences in rates of change; however few variables were significantly associated with intra-individual short-term change over time.     

为照料者实施干预对老年痴呆患者BPSD症状的影响

目的 探讨为照料者实施综合干预对稳定老年痴呆患者精神行为(BPSD)症状的影响.方法 对100例住院老年痴呆患者的照料者实施为期6个月的综合干预,于干预前、干预3,6个月末采用AD病理行为评分量表(BEHAVE-AD)、总体衰退量表(GDS)分别对患者的BPSD症状及痴呆衰退程度进行评定、比较.结果 干预3,6个月末患者BEHAVE-AD总分及除妄想、幻觉外的各因子分均较干预前显著降低;其中尤以攻击行为、焦虑恐惧、行为紊乱因子分值降低最明显.而GDS评分干预前后均无明显变化,差异无统计学意义.结论 为照料者实施综合干预,可有效改善老年痴呆患者BPSD症状,稳定患者病情,利于护理.     

Supporting family dementia caregivers: testing the efficacy of dementia care management on multifaceted caregivers’ burden

ABSTRACT

Objectives: Current research suggests that dementia care management (DCM) can decrease burden and associated health impairments of caregivers. The objective of this secondary analysis is to investigate the impact of DCM on multifaceted caregivers’ burden dimensions by differentiating between objective and subjective burden.

Methods: A sample of n = 317 dyads of caregivers and community-dwelling people with dementia (PwD) participated in a general practitioner-based, cluster-randomized intervention trial (Identifier:NCT01401582) with two arms and comprehensive data assessment at baseline and 12-month follow-up. Data provided by the caregiver included an inventory with 88 items in 20 different dimensions.

Results: Caregivers in the intervention ‘DCM’ group showed decreased caregiver burden, especially in caregivers’ objective burden due to caring (i.e. emotional support), caregivers’ subjective burden due to behavior change (i.e. cognition, aggression and resistance, depression, late symptoms) and caregivers’ subjective burden due to perceived conflicts between needs and responsibilities to care (i.e. financial losses) compared to caregivers in the control ‘care as usual’ group, which showed significant increased caregiver burden after 12 months.

Conclusion: Our findings support evidence for the effectiveness of DCM to lower family dementia caregivers' burden in multifaceted dimensions.     

The role of norepinephrine in the behavioral and psychological symptoms of dementia

The behavioral and psychological symptoms of dementia (BPSD) are common serious problems that are a major contributor to caregiver burden. Despite their significance, the underlying neurobiology of these disturbances is still unclear. This review examines the role of norepinephrine (NE) on BPSD, including depression, aggression, agitation and psychosis. A number of lines of evidence suggest that NE dysfunction leading to BPSD may result from increased NE activity and/or hypersensitive adrenoreceptors compensating for loss of NE neurons with progression of Alzheimer's disease (AD). With greater appreciation of the underlying neurobiology of behavioral and psychological symptoms of dementia (BPSD) more effective, rational, targeted pharmacotherapy will hopefully emerge.     

Trazodone for the treatment of behavioral and psychological symptoms of dementia (BPSD) in Alzheimer's disease: a retrospective study focused on the aggression and negativism in caregiving situations]

Behavioral and psychological symptoms of dementia (BPSD) includes anxiety, depression, hallucination, delusion, aggression, irritability, agitation and wandering. BPSD often causes a deterioration of activity of daily living (ADL) and worsens caregiver burden. Trazodone, an atypical antidepressant, is used for the treatment of BPSD, but the effectiveness is controversial. In this study, we retrospectively analyzed the medical records of the 13 AD patients who were rated as having the aggression and negativism in caregiving situation and were treated by trazodone. The BPSD of the per-treatment stage of the patients was assessed with Neoropsychiatric Inventory(NPI). Improvement of BPSD after trazodone was observed in 9 patients, and the aggression and negativism in caregiving situations were improved in 6 patient. Trazodone may be effect for the treatment of a certain type of BPSD such as aggression and negativism in caregiving situations. Prospective studies of this issue are recommended in AD patient.     

Behavioral and psychological symptoms of dementia in developing countries

BACKGROUND: Little is known about the prevalence of, or associations with behavioral and psychological symptoms of dementia (BPSD) in developing countries. METHODS: Individuals diagnosed as having dementia according to DSM-IV criteria (mild and moderate cases as defined by the Clinical Dementia Rating scale only), together with their main caregiver, were recruited from 21 centers in 17 developing countries. People with dementia were directly assessed with the Community Screening Interview for Dementia and the Geriatric Mental State Schedule (GMS); GMS data were processed by the AGECAT computer program to yield diagnostic information on 8 psychiatric syndromes. Caregivers answered direct questions about behavioral symptoms of dementia (BSD) and completed the Zarit Burden Inventory. RESULTS: At least one BSD was reported in 70.9% of the 555 participants. At least one case-level AGECAT psychiatric syndrome (not including the organic syndrome) was exhibited by 49.5% of people with dementia. Depression syndromes (43.8%) were most common followed by anxiety neurosis (14.2%) and schizophreniform/paranoid psychosis (10.9%). Caregivers were more likely to report BSD in people with dementia who were married, younger and better educated. More advanced dementia, poorer functioning and the presence of depression or anxiety were each associated with BSD. BSD, and psychiatric syndromes (anxiety neurosis and schizophreniform/paranoid psychosis) predicted caregiver strain after controlling for cognitive impairment. BPSD are poorly understood, leading to shame and blame. CONCLUSIONS: BPSD are common among people with dementia in developing countries, though we found marked regional variations. Representative population studies are needed to clarify prevalence and impact, but our research suggests considerable unmet need, with much scope for intervention. Raising awareness of the problem should be the first step.     

A multinational review of recent trends and reports in dementia caregiver burden

This systematic review of the literature focuses on the influence of ethnic, cultural, and geographic factors on the caregivers of patients with dementia. In particular, we explore the impact of cultural expectations on five important questions: 1) Do the characteristics of dementia affect caregiver burden? 2) Do characteristics of the caregiver independently predict burden? 3) Does the caregiver affect patient outcomes? 4) Does support or intervention for caregiver result in reduced caregiver burden or improved patient outcomes? 5) Finally, do patient interventions result in reduced caregiver burden or improved patient outcomes? Our findings suggest that noncognitive, behavioral disturbances of patients with dementia result in increased caregiver burden and that female caregivers bear a particularly heavy burden across cultures, particularly in Asian societies. Caregiver burden influences time to medical presentation of patients with dementia, patient condition at presentation, and patient institutionalization. Moreover, interventions designed to reduce caregiver burden have been largely, although not universally, unsuccessful. Pharmacological treatments for symptoms of dementia were found to be beneficial in reducing caregiver burden. The consistency of findings across studies, geographic regions, cultural differences, and heathcare delivery systems is striking. Yet, there are critical differences in cultural expectations and social resources. Future interventions to reduce caregiver burden must consider these differences, identify patients and caregivers at greatest risk, and develop targeted programs that combine aspects of a number of interventional strategies.     

Antipsychotic treatment of behavioral and psychological symptoms of dementia in geropsychiatric inpatients.

Behavioral/psychological symptoms of dementia (BPSD) affect caregiver burden and transition from home to hospital or long-term care. The authors examined change in BPSD for dementia patients (from hospital admission to discharge) who were prescribed haloperidol (n= 289), olanzapine (n=209), or risperidone (n=500). Olanzapine was associated with significantly greater overall improvement in BPSD (based on the Psychogeriatric Dependency Rating Scale total score) than risperidone or haloperidol. Olanzapine was significantly superior on measures of active-, verbal-, and passive-aggression and delusions/hallucinations to risperidone or haloperidol, and, on manipulative behavior and noisiness, to risperidone. Results support the effectiveness of olanzapine in improving several BPSD in hospitalized dementia patients.     

Longitudinal progression of behavioral and psychological symptoms of dementia: a pilot study from India

Introduction: Behavioral and psychological symptoms of dementia (BPSD) vary across different types, stages and different time spans of dementia. BPSD form an important determinant in the effective management of dementia as they contribute significantly to the prognosis and outcome of dementia. Methods: Thirty‐three individuals with dementia were assessed across three different time periods for changes in behavioral problems as noted on the BEHAV‐AD. Of the 33 individuals, eight had received medications that primarily consisted of low‐dose typical antipsychotics. Results: Although, it was noted that behavioral problems fluctuate over time; significant variations in intensity were noted only in delusions. BPSD variations were similar in both Alzheimer’s and vascular dementia. Individuals on medications showed significant improvement in nearly all behavioral problems and a decrease in caregiver distress. Discussion: Behavioral symptoms vary across different time spans and follow a general pattern. Detailed analyses of these longitudinal variations in BPSD can be useful in planning cost‐effective treatment strategies.