Evidence-Based Practice Interventions for Managing Behavioral and Psychological Symptoms of Dementia in Nursing Home Residents

Behavioral problems and psychological symptoms of dementia (BPSD) are commonly encountered in nursing homes. The literature shows that nonpharmacological methods of controlling undesirable behaviors in patients with dementia include staff education, activity interventions, and sensory stimulation. When these interventions fail, pharmacological therapy may include antipsychotics, cholinesterase inhibitors, and anticonvulsants, which are prescribed for BPSD management off-label. In this article, the author outlines the best evidence-based practice interventions, based on her literature review, for reducing problematic BPSD in the nursing home population. Although the literature supports nonpharmacological treatment as first-line therapy in these patients, there have been no large, high-quality studies conducted to identify which interventions work best in long-term care settings, indicating that this is an area where future research is needed. Additionally, due to the absence of medications approved for BPSD by the US Food and Drug Administration, pharmacovigliance is vital when prescribing available medications in this vulnerable patient population.

Key words: Dementia, nursing home, behavioral problems and psychological symptoms of dementia (BPSD). 
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Behavioral problems are common in long-term care (LTC) patients with dementia and pose a significant burden on staff, affect caregiver well-being, and impact patients’ quality of life. Behavioral and psychological symptoms of dementia (BPSD) is an umbrella term defined by the International Psychogeriatric Association as the “symptoms of disturbed perception, thought content, mood or behavior that frequently occur in patients with dementia.”¹ In the nursing home population, as many as 67% to 78% of patients have dementia and 76% of them display BPSD.² Behavioral symptoms are usually identified on the basis of observation; these can include yelling out, pacing, wandering, resisting care, overdressing (dressing in too many layers of clothing), disrobing in inappropriate areas, sleep disturbances, inappropriate sexual behaviors, hitting, and scratching.^1,2 Psychological symptoms, which are usually assessed on the basis of interviews with patients and their relatives or caregivers, may include depression, psychosis, hallucinations, and delusions.^1,2 A variety of labels have been used to describe patients with BPSD, such as agitated, aggressive, and disruptive.² 

If left untreated, BPSD can contribute to premature institutionalization, an increased cost of care, heightened stress to nursing staff and caregivers, and decreased quality of life for the patient.¹ Thus, the value of early identification of BPSD cannot be underestimated. Once identified, a nonpharmacological approach to treatment is preferred over a pharmacological one. Generally, experts agree that medication should be considered if nonpharmacological approaches have failed, as in the case of patients with psychosis, or if a patient’s behaviors become dangerous. This review aims to identify evidence-based interventions, both pharmacological and nonpharmacological, for managing and mitigating BPSD in nursing home residents. 

Methods 

This literature review included searches of the PubMed/MEDLINE, CINAHL, OhioLink, and OVID databases using the following key words: dementia, behaviors, psychosis, Alzheimer’s, nursing homes, and long-term care facilities. To be included in the review, the study had to be done in an LTC facility and have been conducted no earlier than 2000. Twenty-four articles met these criteria. The quality of the research was critiqued using AGREE (Appraisal of Guidelines for Research and Evaluation) II, an instrument that assesses the methodological rigor and transparency in which practice guidelines are developed and used internationally. According to this tool, articles were graded from 1 (strongly disagree) to 7 (strongly agree) based on the completeness and quality of reporting. A more thorough explanation of the AGREE II can be found at www.agreetrust.org.

Identification of BPSD in Elders 

Before treating problematic behaviors, an adequate assessment of the patient’s medical, neurological, functional, and psychiatric status must be performed.³ Thereafter, an assessment of the behaviors and an attempt to stop these behaviors by treating any contributing illness should be undertaken.³ Contributing illnesses may include pain, urinary tract infection, and pneumonia.¹ Finally, the BPSD should be described in detail, the patient’s medication regimen should be reviewed for possible interactions or side effects, and laboratory data should be reviewed to rule out any endocrine changes and metabolic abnormalities.⁴

Generally, verbal communication is the means by which patients express their needs; however, when verbal communication is limited, behavioral communication often takes its place.⁴ For example, a baby’s only way to communicate hunger, pain, and other needs is by crying, and, therefore, this is not considered a behavioral problem. In a patient with dementia, when communication through reasoning and language skills is lost, behavior becomes the primary form of communication.⁴ The behaviors displayed often represent a way of expressing feelings and needs that the patient cannot verbally communicate.⁴ Labeling the behavior as “bad” or “difficult” disaffirms the alteration that may be distinctive in the behavior.⁴ Although caregivers may feel the patient is being manipulative with the behavior, most patients with dementia lack the cognitive skills to be manipulative, and the behavior stems from the disease process, which has rendered them unable to communicate by any means other than a primitive coping and communication style.⁴ Recognizing behavior as a form of communication, rather than as random meaningless events, will help caregivers better understand their patients’ behaviors and care for their patients in a more compassionate way. A complete analysis of evaluating patients for the presence of BPSD and differentiating it from other disorders, such as conversion disorder or malingering, is beyond the scope of this article.

Nonpharmacological Interventions 

Although nonpharmacological interventions are the first choice for treatment of BPSD, there are very few controlled, well-designed, and significantly powered studies to make a definitive conclusion about their effectiveness in patients with dementia.³ However, most of the research for nonpharmacological interventions of BPSD is focused on caregiver education and sensory stimulation, the latter of which may include activity intervention. 

Caregiver Education 

The approach of the caregiver can have a tremendous effect on the behavior of a patient with dementia. In a study by Burgio and colleagues,⁵ the authors review the efficacy of using a comprehensive behavior management skills training program, which consisted of in-service education, direct observation of nurses’ aides, and direct feedback based on the material learned in training. The finding was that the program resulted in decreased use of ineffective strategies, such as arguing, as well as decreased disruptive vocalization, restlessness, and physical aggression during performance of activities of daily living (ADLs). These results were sustained for 6 months after the study. 

In a study performed by Deudon and colleagues,⁶ the effectiveness of staff education for management of BPSD was evaluated. The training program sought to provide advice on managing specific BPSD and to encourage nursing home staff to use nonpharmacological approaches. The research was conducted in 16 nursing homes with 306 patients with dementia and BPSD. The nursing homes were randomly assigned to an intervention group or to a control group. The intervention group underwent an 8-week staff education and training program, and the main outcomes were assessed using the Cohen-Mansfield Agitation Inventory (CMAI) and an Observation Scale score. Assessments were done at baseline, at the end of the intervention period, and at 12 weeks after the end of the intervention period. The results showed a significant decrease in the global CMAI scores between baseline and week 8 (P>.01), and between baseline and week 20 in the intervention group (P>.01). Significant decreases in CMAI scores were not seen in the control group. The researchers concluded that the intervention reduced BPSD in nursing home residents for at least 3 months after the end of the program.⁶ 

Sensory Stimulation 

Environmental and psychosocial stressors, as well as sensory deprivation, can lead to increased frustration as well as spatial and time disorientation in patients with dementia. In turn, cognitive and behavioral problems may increase.³ Occasionally, environmental manipulation can be used to control behaviors and help patients feel safer.

In a randomized clinical trial performed by Dowling and colleagues,⁷ the use of timed morning or afternoon bright light exposure was performed to test the effects of light therapy on the presence, frequency, severity, and occupational disruptiveness of neuropsychiatric behaviors in nursing home residents with Alzheimer’s disease. The study contained two experimental groups—one received morning light and the other received afternoon light—and one control group, which received only usual indoor light levels. The patients in the experimental groups received the light therapy for 1 hour per day for 10 weeks. Although there were measurable differences between groups regarding agitation/aggression, depression/dysphoria, aberrant motor behavior, and appetite/eating disorders, the magnitude of change was too small to reach statistical significance. 

Kong and colleagues⁸ carried out a systematic review and meta-analysis regarding nonpharmacological interventions for reducing agitation in older adults with dementia. The review included 14 studies, which covered seven areas of psychosocial interventions: sensory intervention, social contact, activities, environmental modifications, caregiver training, combination therapy, and behavioral therapy. The results concluded that only sensory interventions had efficacy in reducing agitation. The types of sensory interventions used in the studies included aromatherapy, thermal bath, calming music, and hand massage. The authors concluded that more research needs to be done to confirm the findings and that future research should use more rigorous methods.

Bharani and Snowden⁹ conducted a systematic review examining interventions for managing behaviors in nursing home residents with dementia and found six randomized controlled trials of training interventions. Four of the trials reported no differences between the intervention and nonintervention groups. The studies involved staff training in combination with plan of care development, training for care in ADLs or psychosocial activities, and training in emotion-oriented care. One study that involved training interventions to provide multisensory stimulation showed significant reduction in CMAI scores in the intervention group compared with the usual-care group. During this study, staff training was supported with multiple supervised meetings and feedback sessions to help support the implementation of the treatment. The study was limited by nonblinded observations and incomplete randomization due to two wards being assigned to the control group. 

Pharmacological Interventions 

The use of medications to treat BPSD is indicated if patients’ behaviors are dangerous or a result of a nondementia-related psychosis.³ Nonpharmacological interventions should be attempted before pharmacological interventions are initiated to reduce the risk of adverse effects associated with polypharmacy in the frail, elderly LTC population.³ Further research is needed in the area of treating BPSD with medication. Due to the multiple state regulations in the nursing home and the need for gradual dose reduction on medications used for psychosis or behaviors, more interventions need to be researched.

Antipsychotics 

Despite safety concerns, antipsychotics are still prescribed for the treatment of behavioral problems in patients with dementia. A recent initiative by the Centers for Medicare & Medicaid Services has called for a reduction of anti-psychotic prescribing in nursing homes by 15% by the end of 2012 given that as many as 40% of residents are prescribed these drugs without a diagnosis of psychosis.¹⁰  

Conventional (first-generation) antipsychotics were the mainstay of BPSD treatment before the introduction of atypical (second-generation) antipsychotics.² According to Madhusoodanan,³ a meta-analysis of controlled trials of conventional antipsychotics in patients with dementia showed an 18% to 26% efficacy rate over placebo. The problem with using conventional antipsychotics in elderly patients with dementia is the high incidence of adverse cardiovascular effects and high risk of death.³ Other side effects include sedation, orthostatic hypotension, and anticholinergic symptoms, such as urinary retention, dry mouth, constipation, visual difficulties, confusion, and further decline in cognitive impairment.¹¹ Extrapyramidal symptoms, such as Parkinson-like symptoms, akathisia, dystonia, and tardive dyskinesia, are also severe side effects of conventional antipsychotics.¹¹ The efficacy and safety profile of atypical antipsychotics is better than conventional antipsychotics in the psychopharmacological management of BPSD; however, none of the atypical antipsychotics are approved by the US Food and Drug Administration (FDA) for the treatment of BPSD.³ Atypical antipsychotics have been the most studied and used class of drugs in the management of BPSD. They have a modest efficacy rate and result in fewer extrapyramidal symptoms, including tardive dyskinesia, compared with conventional antipsychotics.³ 

Risperidone is one of the most studied atypical agents in BPSD. It is associated with a higher level of somnolence when compared with a placebo, but has fewer adverse effects when it comes to extrapyramidal symptoms and falls.¹¹ As with initiating any drug, the risks versus benefits must be discussed with the patient and his or her family.

A post-hoc exploratory analysis of data on 479 nursing home patients with psychosis associated with dementia was performed by Rabinowitz and associates.¹² The study was a 12-week, double-blind, placebo-controlled clinical trial. Inclusion criteria for the trial included a diagnosis of Alzheimer’s disease or mixed dementia with a rating of more than 2 on any delusions or hallucination item of the Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) upon entering the trial. Mean changes from baseline to the end of the trial were examined on the CMAI and BEHAVE-AD. The CMAI assessment showed that risperidone, compared with placebo, significantly reduced cursing or verbal aggression, hitting, repetitious mannerisms, pacing, aimless wandering, hoarding, hiding of things, and repetitive questions or sentences. On the BEHAVE-AD, risperidone showed significant efficacy in reducing physical threats and/or violence, agitation, and verbal outbursts compared with placebo. These findings led the author to conclude that risperidone is effective in treating BPSD.¹² 

In 2005, De Deyn and colleagues¹³ conducted an analysis of pooled data from three randomized, placebo-controlled trials that examined the efficacy and safety of risperidone use in treating agitation, aggression, and psychosis associated with dementia in nursing home patients. The authors’ objective was to assess the risk versus benefit of using risperidone in this population, and they found that the observed mean change at end point on the CMAI total score, total aggression score, BEHAVE-AD total score, and psychotic symptoms score was significantly higher for the risperidone group than for the placebo group. In addition, the incidence of adverse events was comparable between the risperidone and placebo groups, at 84.3% and 83.9%, respectively. Risperidone induced no orthostatic or anticholinergic adverse effects, nor did it increase falls or cognitive decline. At the recommended doses, risperidone displayed a favorable risk-benefit profile, and it was well tolerated with respect to extrapyramidal symptoms, somnolence, and anticholinergic side effects.¹³

However, a systematic review performed by Lee and associates¹⁴ only a year earlier concluded that although atypical anti-psychotic use has increased in the treatment of BPSD, there are few randomized trials to evaluate their use for this purpose. The authors reviewed 77 abstracts and found only five randomized trials evaluating risperidone and olanzapine. In these trials, treatment with an atypical antipsychotic showed improvement from beginning to end point compared with a placebo. There were also two trials comparing risperidone to haloperidol, but these did not find any difference in efficacy between these agents.¹⁴

According to an observational analysis that involved five consulting pharmacist sites,¹⁵ risperidone was preferred over olanzapine because of the decreased need for laxative use and fewer falls. The analysis compared side effects among nursing home residents (47% had a primary diagnosis of Alzheimer’s disease) receiving low-dose risperidone with those receiving low-dose olanzapine. In both groups, there was minimal need for lubricating eye drops and anxiolytic use decreased, but in the olanzapine group, more patients needed laxatives more often and there were more reported falls.¹⁵

Cholinesterase Inhibitors 

Cholinesterase inhibitors are medications used to help delay or prevent the symptoms of dementia from becoming worse. Well-known side effects of these medications include nausea, vomiting, diarrhea, and anorexia. Other lesser known side effects include rhinitis, fatigue, leg cramps, insomnia, abnormal dreams, myasthenia, asthenia, tremor, dizziness, headaches, bradycardia, orthostatic hypotension, syncope, urinary incontinence, seizures, gastrointestinal hemorrhage, extrapyraidal symptoms, and, very rarely, liver dysfunction.¹⁶

Donepezil, rivastigmine, and galantamine have been shown to produce some behavioral benefits over placebos in clinical trials.³ A study by Holmes and associates¹⁷ that evaluated the efficacy of donepezil in patients with mild to moderate Alzheimer’s disease and a score of more than 11 points on the Neuropsychiatric Inventory (NPI) at baseline found that patients treated with donepezil 10 mg daily had marked improvement in their NPI score compared with their placebo-treated counterparts.

Feldman and colleagues¹⁸ conducted a 24-week double-blind trial of patients with moderate to severe Alzheimer’s disease treated with donepezil 10 mg daily. This study also showed a greater reduction in NPI scores in the treatment group than in the placebo group.

In a 26-week, open-label study of rivastigmine by Cummings and colleagues,¹⁹ there was a decrease in the NPI-Nursing Homes scores for a wide range of behavioral disturbances in the subgroup of patients with behavioral symptoms at baseline. The study involved a total of 29 nursing homes, and the effects of rivastigmine 3 mg daily to 12 mg daily were assessed in residents with moderate to severe dementia.

Anticonvulsants 

An article by Porsteinsson²⁰ outlined the results of four placebo-controlled clinical trials that examined the use of divalproex sodium for BPSD. The author found that the outcomes in none of the studies were sufficient to define clinical practice and the results were conflicting and inconclusive. In a review article by Kim and colleagues,²¹ research assessing the use of gabapentin for BPSD was evaluated. In most of the reviewed cases, gabapentin was reported to be well tolerated and an effective treatment for BPSD, but the authors concluded that lack of available data limit the support of its use in the treatment of BPSD. 

Conclusion 

This review identified that there are many different nonpharmacological interventions that have been investigated for the treatment of BPSD in nursing homes, but the studies did not show enough clinical significance to merit changes in practice. Much larger and higher quality studies need to be performed in this area. The studies need to be conducted using nursing home staff and resources that are readily available in nursing homes. Because most nursing homes are for-profit, it would be easy to assume that not a large amount of money will be spent on outside consults or improvements in the environment. 

As for pharmacological treatments for BPSD, there have been many studies done, but no drug is free of side effects. Because most patients with dementia are elderly and take multiple medications, the addition of another agent to treat BPSD can be detrimental to their health. Also, thus far, no pharmacological treatment for BPSD has been FDA-approved. Drugs being used in the treatment of BPSD have been prescribed off-label.

References

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    Disclosures:

    The author reports no relevant financial relationships.

     

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    Rebecca Perkins, RN, BSN, BS

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