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Treating Behavioral and
Psychological Symptoms of
Dementia (BPSD)
Kuang-Yang Hsieh, M.D. ph.D.
Department of Psychiatry
Chimei Medical Center
60 %
20 %
(FTD)
(DLB)
(PD)
Role of neurologist and psychiatrist
in the course of dementia
Psychiatrist:
Early diagnosis and intervention;
Treating BPSD
Neurologist:
Identification and correction of
risk factors;
Early diagnosis and intervention
Mild Cognitive Impairment
Dementia
Treatment of BPSD
Use non-pharmacological treatment first.
 Use of psychiatric medication is not routinely
recommended unless the problem is severe .
In patients with BPSD, the mortality rate was
1.6–1.7-fold higher in the antipsychoticstreated group than in the placebo-treated
group.
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Points for attention about
pharmacotherapy of BPSD
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Sedative and anticholinergic effects of
medications may impede cognitive functions.
Patients with PD or DLB are especially sensitive
to extrapyramidal symptoms.
Start low and go slow.
Be careful of the motor, cognitive, metabolic and
vascular effects of medications. Beware of the
risk of falls.
Assess risk and benefit.
Cholinesterase inhibitors and
memantine are helpful for
BPSD.
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Antipsychotics are effective for
delusion, hallucination, agitation and
aggression.
Second-generation antipsychotics are
recommended. (Risperdal, Zyprexa,
Clozaril, SoLian, Abilify)
Beware of EPS, orthostatic hypotension
and metabolic adverse effects.
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Anticonvulsants are not helpful for
BPSD.
If there is significant poststroke or
posttraumatic epilepsy, choose an
anticonvulsant with less cognitive adverse
effects.
Depakine (valproate) and Lamictal
(lamotrigine) are recommended.
Antidepressants are effective for
depression and anxiety
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Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin and norepinephrine reuptake
inhibitors (SNRIs)
Norepinephrine and specific serotonin
antidepressant (NaSSA)
Norepinephrine and dopamine reuptake
inhibitor (NDRI)
Other serotonin modulators
Tricyclic antidepressants (TCAs)
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Example: Sinequan (doxepin), Tofranil
(imipramine), Deanxit (melitracen)
Inhibiting the reuptake of
norepinephrine and serotonin; blocking
histamine (H1), alpha1-adrenergic and
muscarinic receptors.
Effective for neurogenic pain at low
doses.
Tricyclic antidepressants (TCAs)
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Prominent side effects due to receptor
blocking (sedation, hypotension, blurred
vision, constipation, urinary retention,
dry mouth, exacerbation of glaucoma,
cognitive impairment).
Overdose may be lethal, with
cardiovascular and CNS toxicity.
Not recommended for BPSD.
Selective serotonin reuptake
inhibitors (SSRIs)
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Example: Prozac (fluoxetine), Zoloft (sertraline)
Being more safe, causing less side effects than TCAs.
Inhibiting cytochrome P450 enzymes, thus
increasing the concentration of co-administered
medication.
Side effects: insomnia, sexual dysfunction,
nausea/vomiting. (through 5-HT1, 5-HT2, 5-HT3
receptor signaling respectively)
Effective for disinhibition, impulsivity and repetitive
behavior in FTD.
Serotonin and norepinephrine
reuptake inhibitors (SNRIs)
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Example: Efexor (venlafaxine),
Cymbalta (duloxetine)
More effective for pain and anxiety
symptoms than SSRIs.
Side effects: insomnia, sexual
dysfunction, nausea/vomiting.
Norepinephrine and specific
serotonin antidepressant (NaSSA)
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Example: Remeron (mirtazapine)
Indirectly increasing synaptic norepinephrine and
serotonin through blockade of central presynaptic
alpha2-adrenergic receptors.
Blocking histamine (H1), 5-HT2 and 5-HT3 receptors.
Causing less insomnia, sexual dysfunction,
nausea/vomiting than SSRIs.
Effective for pain, insomnia and anorexia/cachexia.
Side effects: sedation, increased appetite, weight gain.
Norepinephrine and dopamine
reuptake inhibitor (NDRI)
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Example: Wellbutrin (bupropion)
Effective for fatigue, loss of energy.
Causing less sexual dysfunction than SSRIs;
may improve sexual dysfunction associated
with chemotherapy and hormonal therapy.
Additional benefit for smoking cessation .
Side effects: insomnia, tachycardia, seizure.
Other serotonin modulators
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Example: Mesyrel (trazodone)
Inhibiting serotonin reuptake; blocking
histamine (H1) and alpha1-adrenergic
receptors.
Usually used as a hypnotic (10-100 mg/d)
rather than an antidepressant (200-400 mg/d).
Decreasing number of awakenings, increasing
total sleep time and percentage of deep sleep
(stages 3+4).
Side effects: sedation, hypotension, dizziness.
Pharmacotherapy for insomnia
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Mesyrel (trazodone) is the drug of choice.
Be careful of sedative and musclerelaxing effects of benzodiazepines. Avoid
using them in patients with BPSD.
Conclusion
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BPSD should be appropriately treated.
Consider Non-pharmacological treatment
first. Reserve pharmacotherapy for the
second line.
Medication for each patient should be
individually taylored. Risk and benefit
should be carefully assessed.
Consult the psychiatrist when the problem
becomes obvious and out of control.
Thank you for attention