Management of Dementia with Behavioral and Psychological Symptoms of Dementia (BPSD) in Acute Hos... скачать в хорошем качестве

Management of Dementia with Behavioral and Psychological Symptoms of Dementia (BPSD) in Acute Hos...

In this episode of Hospital Medicine Unplugged, we tackle dementia with behavioral and psychological symptoms (BPSD) in the hospitalized patient—why it happens, how to assess it fast, and how to manage it safely without making things worse. We start with the big picture: BPSD affects ＞90% of people with dementia, often driving hospital admissions. Symptoms span agitation, aggression, psychosis, depression, anxiety, apathy, sleep disturbance, and disinhibition—and they’re not benign. In the hospital, BPSD is linked to longer stays, higher mortality, restraint use, staff injury, early institutionalization, and one-third of total dementia care costs. Next, we walk through the do-first inpatient assessment. Rule out delirium (acute onset, fluctuating attention), then hunt for reversible triggers: pain, constipation, urinary retention, infection, hypoxia, metabolic derangements, sleep disruption, and iatrogenic harm from polypharmacy—especially anticholinergics, benzodiazepines, and opioids. Collateral history is critical to establish baseline behavior. Use structured tools like CAM/4AT for delirium, PAINAD for nonverbal pain, and NPI or CMAI to quantify symptoms. The DICE approach (Describe–Investigate–Create–Evaluate) keeps management personalized and efficient. We emphasize that non-pharmacologic strategies are first-line—always. In the hospital, this means person-centered care: reorientation, sleep hygiene, early mobility, sensory optimization (glasses/hearing aids), hydration, toileting, nutrition, and calm communication. Caregiver- and staff-focused interventions have the strongest evidence, reducing both symptom burden and distress. Music therapy, tailored activities, exercise, massage/touch, and multicomponent delirium programs like HELP can meaningfully reduce agitation and prevent escalation. When symptoms threaten safety, we cover how to use meds sparingly and smartly. Before adding anything, do a medication cleanup. Pharmacotherapy is time-limited, lowest dose, shortest duration, and always paired with non-drug strategies. • Cholinesterase inhibitors can modestly improve BPSD over time. • Antipsychotics offer small benefits for severe agitation or psychosis but carry real risks—increased mortality, stroke, sedation, EPS, QT prolongation, and functional decline. No clear winner among agents. Use hours to days, reassess daily, and document risk–benefit discussions. Avoid dopamine blockers in Lewy body dementia; if unavoidable, extreme caution. • SSRIs help depression/anxiety; evidence for agitation is limited. Mirtazapine doesn’t help agitation. • Benzodiazepines and valproate are generally avoid. • Pain control matters—untreated pain fuels agitation. We close with hospital pearls: no routine drugs for delirium; antipsychotics only for dangerous behaviors refractory to non-drug care. Plan early for deprescribing—one-third of patients started on antipsychotics in the hospital leave on them unless you stop it. At discharge, communicate what worked: triggers, de-escalation strategies, sleep plans, toileting schedules, and a clear reassessment plan. Align care with goals, dignity, and function. Bottom line: Treat the cause, lead with non-pharmacologic care, reserve meds for safety, reassess relentlessly, and deprescribe early.