Interventional psychiatry in the management of behavioural and psychological symptoms of dementia: a qualitative review

Abstract

INTRODUCTION: "Behavioural and psychological symptoms of dementia" (BPSD) refers to a heterogeneous group of clinical manifestations related to dementia, including apathy, depression, anxiety, delusions, hallucinations, sexual or social disinhibition, sleep-wake cycle disturbances, aggression, agitation and other behaviours considered inappropriate. Because of the complexity and heterogeneity of BPSD, as well as the fragility and multimorbidity of the elderly, pharmacological treatment appears to be limited in terms of safety and efficacy, and nonpharmacological therapies are today considered the first choice. There is growing evidence that interventional approaches such as electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS) could be safe and efficient options for several psychiatric illnesses in a population presenting resistance to and/or intolerance of pharmacotherapy.AIMS: The aim of the present work is to provide a qualitative review of the state of the art in interventional psychiatry in the treatment of BPSD. A particular focus will be on depression and agitation, which represent major stressors on caregivers and a primary cause of institutionalisation. CONCLUSIONS: ECT is probably the most promising interventional procedure needing further investigation in order to obtain specific protocols and a consensus on indications. Preliminary data on rTMS, tDCS, and VNS are encouraging although randomised controlled trials to investigate and compare their efficacy in the treatment of BPSD are still lacking. Their feasibility profile could represent an important advantage over ECT. DBS could represent a very effective therapy for behavioural disorders, but knowledge of the precise neuroanatomical targets for BPSD is currently too limited to justify this invasive approach.

Neuromodulation for Apathy in Alzheimer’s Disease: A Double-Blind, Randomized, Sham-Controlled Pilot Study

“…Short-term trials indicate that the stimulant methylphenidate improves apathy in patients with AD [17][18][19], but many individuals cannot tolerate stimulants due to cardiovascular concerns [20]. Thus, non-pharmacological treatment options for apathy are urgently needed [21].…”

Risk Assessment of Electroconvulsive Therapy in Clinical Routine: A 3-Year Analysis of Life-Threatening Events in More Than 3,000 Treatment Sessions

“…German treatment guidelines follow a rather ECT-supportive path but limit the first-line indication for ECT to delusional depression, depressive stupor, schizoaffective psychosis with severe depressive mood, major depression with high suicidality or refusal to eat, and acute life-threatening pernicious catatonia ( Folkerts et al, 2003 ). The medical profession behind the statement has established that “refraining from ECT would mean an ethically unjustifiable restriction of the right of critically ill patients, who are often at risk for suicidal behavior, to get the best possible treatment.” In line with this position, review publications ( Kellner et al, 2020 ) and meta-analyses suggest to advertise ECT progressively to be used in a wider indication even in patients with potential risk profiles as ECT has been proven to be effective and safe during the first trimester of pregnancy ( Calaway et al, 2016 ) in children ( Døssing and Pagsberg, 2021 ) as well as in old-old adults aged 80 years and older ( Plakiotis et al, 2014 ; Kellner et al, 2016 ; McCall et al, 2018 ), and in patients with behavioral and psychological symptoms of dementia ( Swierkosz-Lenart et al, 2019 ).…”

BPSD reconsidered: diagnostic considerations to preserve personhood in persons with dementia

“…Dementia has rapidly become a major global health problem and can result from various diseases (Kwon and Lee, 2021 ), with Alzheimer's disease (AD) as the most representative and common form, affecting over 50 million people worldwide (Alzheimer's disease facts figures, 2023 ). While the most salient feature of AD is progressive memory impairment, behavioral and psychological symptoms of dementia (BPSD) may also emerge over the progression of the disease process with considerable variability and heterogeneity (Swierkosz-Lenart et al, 2019 ). BPSD is an umbrella term that characterizes neuropsychiatric (i.e., non-cognitive) manifestations including, but not limited to, agitation; irritability; depression; anxiety; delusions; (Swierkosz-Lenart et al, 2019 ; Felstead et al, 2022 ); hallucinations; aggression; and other behaviors considered to be inappropriate (Swierkosz-Lenart et al, 2019 ).…”

“…While the most salient feature of AD is progressive memory impairment, behavioral and psychological symptoms of dementia (BPSD) may also emerge over the progression of the disease process with considerable variability and heterogeneity (Swierkosz-Lenart et al, 2019 ). BPSD is an umbrella term that characterizes neuropsychiatric (i.e., non-cognitive) manifestations including, but not limited to, agitation; irritability; depression; anxiety; delusions; (Swierkosz-Lenart et al, 2019 ; Felstead et al, 2022 ); hallucinations; aggression; and other behaviors considered to be inappropriate (Swierkosz-Lenart et al, 2019 ). Importantly, these behaviors are a reflection of a high level of distress felt by the person with dementia and are distressing to loved ones and those providing care (NICE, 2018 ).…”