19 - Non drug measures

Non-drug measures

Prescribing in older people CHAPTER 6 Management of behavioural and psychological symptoms of dementia (BPSD) Behavioural and psychological symptoms of dementia (BPSD) cover a range of difficulties including aggression, agitation, vocalisation, distress during care, disinhibition, hallucinations, delusions, apathy, low mood and anxiety.1 Such symptoms occur in over 90% of patients to varying degrees.2 Drug treatment of BPSD is not well supported by evidence3 and many of the drugs used in BPSD have serious adverse effects. Non-­drug measures Since the publication in the UK of Time for Action, a report which highlighted the risks of antipsychotic use in dementia,4 there has been a drive to formulate and employ non-­ pharmacological treatment for BPSD. Systematic reviews have been completed,5 new models of care developed6,7 and guidance documents written.8 The key themes include:

1. An individualised approach rather than the application of more generalised therapies.
2. Ensuring contributory physical factors are addressed as a first step. These factors include pain (see following section), infection, constipation and medication adverse effects (see ‘Safer prescribing for physical conditions in dementia’ earlier in this chapter).
3. The importance of understanding and reframing ‘problem behaviours’ as an expression of distress and unmet need.6,7
4. Use of life history, direct observation of care and data collection (e.g. sleep, pain and ABC charts) to uncover unmet needs and to inform treatment.8
5. Formulation meetings to develop a model of the factors contributing to the behaviour.
6. Clear care plans developed with carers to address unmet needs.
7. Care plans reviewed and adjusted according to effectiveness of the interventions tried. Some structured psychosocial interventions for BPSD9 are supported by research.10 These can be useful to consider within an individualised care plan and are better if  implemented by supporting caregivers. Behavioural management techniques and ­caregiver psychoeducation centred on an individual patient’s behaviour have been found to be generally successful and the effects can last for months.11 A 2017 systematic review of systematic reviews12 provided a comprehensive summary of the evidence for non-­pharmacological interventions in BPSD. Among sensory stimulation interventions, the only convincingly effective intervention (reducing agitation and aggressive behaviour) was music therapy.12,13 Multicomponent interventions that use a comprehensive, integrated multidisciplinary approach combining medical, psychiatric and nursing interventions may be more effective at reducing severe behavioural problems in nursing home patients.12 Animal-­assisted therapy has shown a significant reduction in BPSD, especially depression.14 Doll therapy has been shown to reduce agitation, aggressiveness as well as dysphoria, wandering, apathy, professional caregiver burden and delirium.15 Increasing light exposure and bright light therapy may be beneficial in BPSD and sundowning.16,17 A systematic review suggested that aerobic exercise might be effective in reducing neuropsychiatric symptoms.18 A 2020 Cochrane