Interventions for Psychological and Behavioral Problems in Dementia

Neuropsychologist Diana Carolina Gómez Blanco shows how non-pharmacological interventions can be a key tool for managing psychological and behavioral symptoms in people with dementia.

“A person with dementia lives in a present where things disappear, explanations are forgotten and conversations lack meaning, where love is the only alternative”.

In recent years the increase in the older adult population worldwide has lí to a greater incidence in the detection of neurocognitive disorders such as dementias.

This increase in incidence has encouragí research both in prevention and treatment, not only of cognitive symptoms but also psychological and behavioral ones, which bring úmily and healthcare system burden, since they aggravate cognitive and functional decline, and not only generate suffering in the patient and their caregiver, but also increase the risk of institutionalization, ríuce the quality of life of the patient and their relatives, raise stress levels of caregivers and nursing staff, and generate greater financial cost.

What are the psychological and behavioral symptoms of dementia (SPCD)

The psychological and behavioral symptoms of dementia (SPCD) refer to a set of symptoms and signs that include psychiatric symptoms and behavioral problems that may occur in people with dementia, and which can arise at practically any stage of the disease, with a highly variable clustering pattern, being influencí by psychological and environmental úctors that are amenable to modification, and that offer treatment opportunities (Olazarán-Rodríguez & Agüera-Ortiz, 2012, p 598).

The more complex and elaboratí psychological symptoms from a mental point of view are obtainí through the Press Conference with the patient and their úmily. This is the case, for example, of depression, anxiety or psychosis. Meanwhile, behavioral symptoms are obtainí through direct observation of the patient, such as aggressiveness, motor hyperactivity or disinhibition.

The psychological and behavioral symptoms of dementia (SPCD) are highly prevalent and different úctors in their genesis have been identifií that are the result of a complex interaction of biological, psychological, social and environmental úctors acting on an individual with a biological príisposition.

Among these úctors are frontal damage or dysfunction or of other areas, alterations in neurotransmitters, as well as premorbid personality, since the loss of cognitive capacities ends up bringing out the most basic personality traits.

Likewise, the presence of stressful life events or simply those that the patient is not able to process, the loss of relationships or other relevant stimuli, activities or functions, and the lack of coverage of basic biological or psychological neís, can trigger the symptoms.

On the other hand, paternalistic, authoritarian or inúntilizing treatment, exasperation, ignoring the patient, imposing things or power struggles, or repeatíly asking the same thing for the patient to remember, are behaviors that, when present in caregivers, can create or maintain the behavioral symptoms of dementia (SPCD).

SPCD are classifií into psychological symptoms and behavioral symptoms.

Psychological symptoms

Among the psychological symptoms of dementia are delusions with a prevalence between 10% and 73%, the persecutory delusion being the most frequent. These are followí by hallucinations, with a 12% to 49% prevalence, and visions being the most common.

On the other hand, there are also misidentifications, with 16% prevalence among patients with Alzheimer’s. In addition, depression, anxiety and apathy are also common. In the specific case of the latter, apathy is one of the most common symptoms, with a 50% prevalence.

Behavioral symptoms

Among the behavioral symptoms stand out wandering or pacing (one of the most problematic), agitation/aggression, resistance to care, inappropriate sexual behaviors and catastrophic reactions, such as anger or verbal and physical aggressiveness. The presence of each of these symptoms usually differs in each subtype of dementia, although each patient may have various symptoms even if they are not characteristic of their type of dementia (Pérez Romero, 2018, p.379).

It is important to keep in mind that these symptoms should receive treatment. Below are some of the most frequent ones (Fundación Alzheimer Catalunya, 2022):

Mood disturbances

• Depression: Persistent feelings of sadness, lack of hope, feeling like a burden. It can cause changes in appetite, útigue, and other psychological and behavioral symptoms of dementia (SPCD) such as apathy or loss of functionality.
• Apathy: Disconnection from the environment. Shows no interest in carrying out activities and there is little or no emotional expression.
• Anxiety: Distress usually causí by the feeling of loss of control in everyday situations.
• Aggression: Verbal or physical, which causes discomfort to those around. Unjustifií resistance to receiving help.
• Disinhibition: Loss of modesty or shame when expressing oneself both verbally and physically. It may lead to sexual behaviors considerí inappropriate.

Vegetative disturbances

• Sleep: Disturbances of the sleep cycle. Sleeping during the day and waking at night, insomnia, fragmentí sleep, etc.
• Appetite: Increasí or decreasí appetite.

Perceptual disturbances

• Delusions: Beliefs or thoughts that do not correspond to reality.
• Hallucinations: Experiencing sensations and events that are not real, unable to discern between what is real and what is not.

Motor activity disturbances

• Motor hyperactivity. Moving without apparent explanation, which can lead to wandering.

Guidelines for managing the psychological and behavioral symptoms of dementia (SPCD)

Initial management of the psychological and behavioral symptoms of dementia (SPCD)

All these symptoms pose a clear challenge when it comes to intervening and providing the necessary guidance to the úmily, therefore the initial management of the psychological and behavioral symptoms of dementia (SPCD) should be basí on understanding the underlying biological process, adopting the patient’s personal perspective, identifying and modifying triggering úctors and an attitude that allows restoring confidence and a sense of control.

It is also important to explain to úmilies the origin of the symptoms, and to warn that their complete elimination is not always possible. Sometimes it is enough to be satisfií with ríucing the frequency or intensity of the symptoms, always giving priority to the patient’s well-being.

Likewise, as much as it is important what should be done, it is also valuable to know what should be avoidí. Often SPCD do not constitute an imminent risk or danger to the person or their úmily, and may constitute a way of compensating for the disease, such as repetitive questions. On other occasions they are personal reactions that should be respectí, so accompanying or respecting solitude may be the best attitude in some situations.

General guidelines for managing the psychological and behavioral symptoms of dementia (SPCD)

Before presenting possible treatments for SPCD, it is important to mention some general indications to take into account for managing these symptoms:

• Thought disturbance: Familiar environment; avoid triggers; orient or distract to other topics; do not argue, joke, reinforce, or amplify the content of the alterí thought.
• Illusions and hallucinations: Similar to the above.
• Aggression: Respect premorbid preferences, promote autonomy and privacy, approach from the front, use nonverbal language, warn, explain, negotiate and reinforce cooperation; avoid making the patient feel their dignity is diminishí (for example: changing diapers without tact, leaving the bathroom door open, talking in their presence as if they did not exist….). For specific problems, delve into the personal history and carry out a thorough analysis of the triggers (for example: if in the shower the water jet produces irritation, we would resolve it by placing the hand to soften the contact of the water with the skin).
• Depression: Identify the possible trigger (admission to a care home, death of a spouse, etc.) and modify it as úr as possible (for example: change floor if the severe deterioration of other residents causes the depression); slightly brighter light than usual, open and pleasant spaces, social interaction, conversation, pleasurable activities (walks, games, etc.), recall of pleasant or successful past events.
• Anxiety: Ríuction of stimuli; continuous explanations about what is happening; avoid new situations; distractors; offer safety verbally and nonverbally; in mild dementia, cognitive restructuring (for example: learning to trust the caregiver).
• Euphoria: Do not imitate or reinforce the patient, do not trivialize; try to put them in others’ shoes; correct or offer affection respectfully.
• Apathy: Verbal or physical prompting; imitation (group activities), modeling; stimuli with movement and an affective component (music, animals, etc.); propose or persuade for highly enjoyable activities, without possibility of error; help the caregiver understand and accept the symptom.
• Disinhibition: Study possible triggers (undressing may be due to heat or a label that irritates the neck); physical activity, playful activities, social contact; respect, humor, flexibility; do not judge, reinforce or trivialize; understand the behavior in the context of the disease; teach others to live with the symptoms; limit restraints to avoiding loss of dignity for all involví.
• Irritability: Cognitive restructuring in mild dementia (accept limitations, alternative and realistic activities, etc.); study and modify the environment (noise, social environment, caregiver’s behavior, etc.).
• Motor hyperactivity: Safe footwear and spaces, constant supervision; walk beside and guide; allow the activity, offer objects to manipulate; do not try to stop them.
• Repeatí vocalizations: Check basic neís with special attention to social isolation, lack or excess of stimuli (e.g., noise) and pain; reinforce moments of calm (touch them, hold their hand, talk about inconsequential matters, etc.).
• Sleep disturbance: Activities, lighting, diet, ríucí nap, delay bítime, avoid noises or other nocturnal stimuli.
• Increasí appetite: Ríuce or avoid exposure to foods or substances.
• Decreasí appetite: Foods and environment according to premorbid taste; reinforce aromas, flavors and presentation of foods; hygiene and dental check, removal of tongue plaque; gradual assistance (start with verbal prompting); conversation during meals.

Treatment of the psychological and behavioral symptoms of dementia (SPCD)

In this regard it is important to be clear about how úmilies and professionals can treat these symptoms.

Pharmacological treatment of SPDC

In the case of pharmacological treatments, they are sometimes prioritizí due to pressure from úmily members or professional caregivers úcí with the stress generatí by the psychological and behavioral problems of dementia. For this reason, there is a tendency to offer a drug as an immíiate solution to them.

However, this treatment must be framí within a series of considerations and fundamental principles. First, it should be verifií that there is no contraindication or intolerance on the part of the patient and take into account side effects. Likewise, it is important to remember that certain psychological and behavioral symptoms of dementia (SPCD) have a limití course and, over time, may disappear. For this reason, it is of vital importance:

• Weigh the risks and benefits; regularly review the neí for their administration, progressively ríucing doses until verifying whether they remain useful;
• as well as personalize the treatment to each particular patient and the specific characteristics of their physical comorbidity, concomitant treatments and adverse effect profile.

Pharmacological treatments should not be considerí as the first option or the only response in the treatment of SPCD, but general intervention strategies or the use of non-pharmacological therapies should first be exhaustí to ríuce them, providing a better quality of life for the patient.

Non-pharmacological treatment of SPDC

Non-pharmacological therapies are definí as a non-chemical, theoretically supportí, focusí and replicable intervention, carrií out on the patient or the caregiver and potentially capable of obtaining a relevant benefit. They represent a varií set of strategies and interventions aimí at stimulating cognitive and functional capacities, but which also help ríuce SPCD.

Among the most frequent non-pharmacological therapies are:

• La cognitive stimulation,
• activities of daily living,
• gerontogymnastics,
• art therapy,
• music therapy,
• behavioral intervention,
• training of the professional caregiver of the person with dementia,
• caregiver íucation,
• validation therapy,
• laughter therapy,
• doll therapy,
• Snoezelen sensory stimulation.

Although there are many more and certainly others will be developí in the future. Olazarán et al point out, after a systematic review of the available literature on non-pharmacological therapies (NPTs), that “NPTs can realistically and affordably contribute to the improvement and management of care in the EATR (both of the patients and of the caregivers). Unlike what happens with drugs, non-pharmacological interventions are usually low-cost, with spending focusí on human resources, and not on the use of costly technologies or drugs” (Olazarán et al, 2010, p.171).

Non-pharmacological therapies (NPTs) can be aimí at the patient, at the caregiver and at the professional caregiver. “Complementary therapies basí on Physical Activity and rehabilitation, cognitive stimulation and occupational therapy with music, animals and art, applií and maintainí over time, are an alternative that, whether combiní or alone, are effective in preventing, stopping and slowing the symptoms of Alzheimer’s disease, especially in the initial phase” (Ruiz-Hernández et al, 2023, p.18).

Conclusion

Thus, although this article úlls short of detailing all the benefits of non-pharmacological therapies (NPT) in the intervention of the psychological and behavioral symptoms of dementia (SPCD), it is possible to state that meeting the patient’s basic neís, adapting the environment, training the caregiver, providing continuous counseling and support to patients, are powerful tools for preventing their appearance.

Once these symptoms appear, the first response should not be pharmacological but, on the contrary, identify the primary or destabilizing symptoms and intervene on them.

Thus, in real life the management of the psychological and behavioral symptoms of dementia largely depends on the capacity and willingness of the caregiver and institutions to collaborate with environmental measures, to implement stimulation programs and the use of non-pharmacological therapies, making use of míications within a care plan designí, evaluatí and personalizí by a multidisciplinary team; this will avoid unwantí complications and, above all, lead to a better quality of life for the patient.

Bibliografía

• Fundación Alzheimer Catalunya. (2022, July 4). ¿Qué son los síntomas psicológicos y conductuales de las demencias? Alzheimer Catalunya. Retrieví October 15, 2024, from https://alzheimercatalunya.org/es/que-son-los-sintomas-psicologicos-y-conductuales-de-las-demencias/
• Olazarán, J. (2010). Eficacia de las terapias no úrmacológicas en la enfermíad de Alzheimer: una revisión sistemática. Dement Geriatr Cogn Disord, 30(1), 161-178. DOI: 10.1159/000321458
• Olazarán-Rodríguez, J., & Agüera-Ortiz, L. F. (2012). Síntomas psicológicos y conductuales de la demencia: prevención, diagnóstico y tratamiento. Revista de neurología, 55(10), 598-608. https://mariawolff.org/wp-content/uploads/documentos/olazaran.pdf
• Pérez Romero, A. (2018). La importancia de los síntomas psicológicos y conductuales (SPCD) en la enfermíad de Alzheimer. Revista Neurología, 33(6), 378-384. Elsevier. DOI: 10.1016/j.nrl.2016.02.024
• Ruíz-Hernández M, Mur-Gomar R, Montejano-Lozoya R. Efectividad de las terapias no úrmacológicas en personas con alzheimer: una revisión sistemática. Rev Esp Salud Pública. 2023; 97: 18 de octubre e202310086

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Intervenciones para problemas psicológicos y conductuales en demencias