Behavioral and psychological symptoms in dementia is not a unitary concept: A critical review with emphasis on Alzheimer's disease

Laks, Jerson; Engelhardt, Eliasz

doi:10.1590/S1980-57642009DN20400007

Abstract

Behavioral and Psychological Symptoms of Dementia (BPSD) is an important feature of dementia. However, this definition comprises a large array of symptoms and syndromes. This hampers understanding of the behavior of patients with dementia and the devising of strategies to ameliorate these symptoms. Objectives: This review aimed to describe the main factors and syndromes that comprise BPSD, as well as neuroimaging, psychopharmacological, and genetic data derived from studies of these factors. Methods: A search on the Medline, Scielo, and ISI databases was performed using the keyword BPSD for articles published within the last five years. Selected publications were favored, so this review should not be regarded as a systematic study on the subject. Results: The main factors and syndromes comprising BPSD were identified, namely psychosis, depression, and activity. Different ways of clustering symptoms were considered. The main manifestations of psychosis, apathy and depression were focused, relating phenomenology to neuroimaging and pharmacological issues. Conclusions: BPSD is a heterogeneous array of symptoms which can be better understood as clusters. At least three factors can be separated in BSPD, namely psychosis, depression, and activity. This division may offer guidance to clinicians regarding treatment management and follow up of the chosen therapeutic strategy.

Key words:
BPSD; dementia; psychosis; depression; apathy; elderly.

Resumo

Os Sintomas Psicológicos e do Comportamento na Demência (SPCD) são uma característica importante das demências. Entretanto, essa definição congrega uma ampla gama de sintomas e síndromes. Essa é uma fonte de problemas no que tange o melhor conhecimento do comportamento dos pacientes e daí o desenvolvimento de estratégias para aliviar esses sintomas. Objetivos: Essa revisão objetiva descrever os principais fatores e síndromes que compõem os SPCD, além de alguns dados de neuroimagem, psicofarmacológicos e genéticos derivados do estudo desses fatores. Métodos: Foi realizada busca nos bancos de dados Medline, Scielo e ISI utilizando a palavra chave BPSD (SPCD) compreendendo os cinco últimos anos. Foram privilegiadas publicações selecionadas, de modo que a presente revisão não deve ser vista como do tipo sistemática sobre o assunto. Resultados: Os principais fatores e síndromes que compõem os SPCD foram identificados, compreendendo psicose, depresão e atividade. São consideradas diferentes maneiras de se conglomerar os sintomas. As manifestações principais, psicose, apatia e depressão são focalizados, relacionando a fenomenologia à aspectos de neuroimagem e farmacológicos. Conclusões: Os SPCD constituem um conjunto heterogêneo de sintomas que podem ser melhor compreendidos como conglomerados. Ao menos três fatores podem ser separados nos SPCD, psicose, depressão e atividade. Essa divisão pode oferecer uma melhor orientação para o clínico visando o tratamento e o seguimento da resposta a uma determinada estratégia terapêutica escolhida.

Palavras-chave:
SPCD; demência; psicose; depressão; apatia; idoso.

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References

¹
Finkel SL, Costa e Silva J, Cohen G, Miller S, Sartorius N. Behavioral and psychological signs and symptoms of dementia: A consensus statement on current knowledge and implications for research and treatment. Int J Geriatr Psychiatry 1997;12:1060-1061.
²
Selbaek G, Kirkevold O, Engedal K. The prevalence of psychiatric symptoms and behavioural disturbances and the use of psychotropic drugs in Norwegian nursing homes. Int J Geriatr Psychiatry 2007;22:843-849.
³
Lyketsos CG, Lopez O, Jones B, et al. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the Cardiovascular Health Study. JAMA 2002;288:1475-1483.
⁴
Tatsch MF, Bottino CMC, Azevedo D, et al. Neuropsychiatric symptoms in Alzheimer disease and cognitively impaired, nondemented elderly from a community-based sample in Brazil: Prevalence and relationship with dementia severity. Am J Geriatr Psychiatry 2006;14:438-445.
⁵
McCallion P, McCarron M, Nickle T. Dementia and carer burnout: usefulness of the Maslach Burnout Inventory. J Appl Res Int Dis 2006;19:230.
⁶
Murman DL, Colenda CC. The economic impact of neuropsychiatric symptoms in Alzheimer's disease: can drugs ease the burden? Pharmacoeconomics 2005; 23:227-234.
⁷
Mayer LS, Bay RC, Politis A, et al. Comparison of three rating scales as outcome measures for treatment trials of depression in Alzheimer disease: findings from DIADS. Int J Geriatr Psychiatry 2006;21:930-936.
⁸
Lyketsos CG. Neuropsychiatric symptoms (behavioral and psychological symptoms of dementia) and the development of dementia treatments. Intl Psychogeriatr 2007; 19:409-420.
⁹
Schneider LS, Dagerman, K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry 2006;14:191-210.
¹⁰
Schneider LS, Dagerman K, Insel PS. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2006;294:1934-1943.
¹¹
Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA 2005;293:596-608.
¹²
Aalten P, de Vugt ME, Jaspers N, Jolles J, Verhey FR. The course of neuropsychiatric symptoms in dementia. Part II: Relationships among behavioural sub-syndromes and the influence of clinical variables. Int J Geriatr Psychiatry 2005; 20:531-536.
¹³
Petrovic M, Hurt C, Collins D, et al. Clustering of behavioural and psychological symptoms in dementia (BPSD): A European Alzheimer's disease consortium (EADC) study. Acta Clin Belg 2007;62:426-432.
¹⁴
Robert PH, Frans RJ, Verhey E, et al. Grouping for behavioral and psychological symptoms in dementia: clinical and biological aspects. Consensus paper of the European Alzheimer disease consortium. Eur Psychiatry 2005;20:490-496.
¹⁵
Hollingworth P, Hamshere ML, Moskvina V, et al. Four components describe behavioral symptoms in 1,120 individuals with late-onset Alzheimer's disease. J Am Geriatr Soc 2006; 54:1348-1354.
¹⁶
Jeste DV, Finkel SI. Psychosis of Alzheimer's disease and related dementias. Diagnostic criteria for a distinct syndrome. Am J Geriatr Psychiatry 2000;8:29-34.
¹⁷
Lyketsos CG, Rabins PV, Breitner JCS. An evidence-based proposal for the classification of neuropsychiatric disturbance in Alzheimer's disease. Int J Geriatr Psychiatry 2001;16:1037-1042.
¹⁸
Olin JT, Schneider LS, Katz IR, et al. Provisional diagnostic criteria for depression of Alzheimer disease. Am J Geriatr Psychiatry 2002;10:125-128.
¹⁹
Maertens K, Marien P, Vloeberghs E, et al. Behavioural and neuropsychological correlates of frontal lobe features in dementia. Psychol Med 2006;36:1173-1182.
²⁰
Shinno H, Inagaki T, Miyaoka T, et al. A decrease in N-acetylaspartate and an increase in myoinositol in the anterior cingulate gyrus are associated with behavioral and psychological symptoms in Alzheimer's disease. J Neurol Sci 2007;260:132-138.
²¹
Morana EK, Becker JA, Satlin A, Lyoo K, Fischman AJ, Johnson KA. Psychosis of Alzheimer's disease: Gender differences in regional perfusion. Neurobiol Aging 2008;29:1218-1225.
²²
Garcia-Allozaa M, Gil-Beaa FJ, Diez-Arizaa M, et al. Cholinergic-serotonergic imbalance contributes to cognitive and behavioral symptoms in Alzheimer's disease. Neuropsychologia 2005;43:442-449.
²³
Garcia-Alloza M, Hirst WD, Chen CPLH, Lasheras B, Francis PT, Ramirez MJ. Differential involvement of 5- HT1B/1D and 5-HT6 receptors in cognitive and non-cognitive symptoms in Alzheimer's disease. Neuropsychopharmacology 2004; 29:410-416.
²⁴
Pritchard AL, Harris J, Pritchard CW, et al. Role of 5HT2A and 5HT2C polymorphisms in behavioural and psychological symptoms of Alzheimer's disease. Neurobiol Aging 2008;29:341-347.
²⁵
Cryan JF, Kaupmann K. Don't worry 'B' happy!: a role for GABA(B) receptors in anxiety and depression. Trends Pharmacol Sci 2005;26:36-43.
²⁶
Miczek KA, Fish EW, De Bold JF. Neurosteroids, GABAA receptors, and escalated aggressive behavior. Horm Behav 2003;44:242-257.
²⁷
Engelhardt E, Laks J, Cavalcanti JLS. O sistema glutamatérgico e a doença de Alzheimer. Rev Bras Neurol 2003;39:5-20.
²⁸
Lanctôt KL, Herrmann N, Rothenburg L, Eryavec G. Behavioral correlates of GABAergic disruption in Alzheimer's disease. Int Psychogeriatr 2007;19:151-158.
²⁹
Garcia-Alloza M, Tsang SW, Gil-Bea FJ, et al. Involvement of the GABAergic system in depressive symptoms of Alzheimer's disease. Neurobiol Aging 2006;27:1110-1117.
³⁰
Guimarães HC, Levy R, Teixeira AL, Beato RG, Caramelli P. Neurobiology of apathy in Alzheimer's disease. Arq Neuropsiquiatr 2008; 66:436-443.
³¹
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-284.
³²
Barca ML, Selbaek G, Laks J, Engedal K. The pattern of depressive symptoms and factor analysis of the Cornell Scale among patients in Norwegian nursing homes. Int J Geriatr Psychiatry 2008;23:1058-1065.
³³
Skogseth R, Mulugeta E, Ballard C, et al. Neuropsychiatric correlates of cerebrospinal fluid biomarkers in Alzheimer's disease. Dement Geriatr Cogn Disord 2008;25:559-563.
³⁴
McKeith IG, Dickson DW, Lowe J, et al. Consortium on DLB. Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium. Neurology 2005;65: 1863-1872.
³⁵
Borroni B, Agosti C, Padovani A. Behavioral and psychological symptoms in dementia with Lewy-bodies (DLB): frequency and relationship with disease severity and motor impairment. Arch Gerontol Geriatr 2008;46:101-106.

Publication Dates

Publication in this collection
Oct-Dec 2008

History

Received
07 Oct 2008
Accepted
08 Nov 2008

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Finkel SL, Costa e Silva J, Cohen G, Miller S, Sartorius N. Behavioral and psychological signs and symptoms of dementia: A consensus statement on current knowledge and implications for research and treatment. Int J Geriatr Psychiatry 1997;12:1060-1061.

[2] ²
Selbaek G, Kirkevold O, Engedal K. The prevalence of psychiatric symptoms and behavioural disturbances and the use of psychotropic drugs in Norwegian nursing homes. Int J Geriatr Psychiatry 2007;22:843-849.

[3] ³
Lyketsos CG, Lopez O, Jones B, et al. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the Cardiovascular Health Study. JAMA 2002;288:1475-1483.

[4] ⁴
Tatsch MF, Bottino CMC, Azevedo D, et al. Neuropsychiatric symptoms in Alzheimer disease and cognitively impaired, nondemented elderly from a community-based sample in Brazil: Prevalence and relationship with dementia severity. Am J Geriatr Psychiatry 2006;14:438-445.

[5] ⁵
McCallion P, McCarron M, Nickle T. Dementia and carer burnout: usefulness of the Maslach Burnout Inventory. J Appl Res Int Dis 2006;19:230.

[6] ⁶
Murman DL, Colenda CC. The economic impact of neuropsychiatric symptoms in Alzheimer's disease: can drugs ease the burden? Pharmacoeconomics 2005; 23:227-234.

[7] ⁷
Mayer LS, Bay RC, Politis A, et al. Comparison of three rating scales as outcome measures for treatment trials of depression in Alzheimer disease: findings from DIADS. Int J Geriatr Psychiatry 2006;21:930-936.

[8] ⁸
Lyketsos CG. Neuropsychiatric symptoms (behavioral and psychological symptoms of dementia) and the development of dementia treatments. Intl Psychogeriatr 2007; 19:409-420.

[9] ⁹
Schneider LS, Dagerman, K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry 2006;14:191-210.

[10] ¹⁰
Schneider LS, Dagerman K, Insel PS. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2006;294:1934-1943.

[11] ¹¹
Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA 2005;293:596-608.

[12] ¹²
Aalten P, de Vugt ME, Jaspers N, Jolles J, Verhey FR. The course of neuropsychiatric symptoms in dementia. Part II: Relationships among behavioural sub-syndromes and the influence of clinical variables. Int J Geriatr Psychiatry 2005; 20:531-536.

[13] ¹³
Petrovic M, Hurt C, Collins D, et al. Clustering of behavioural and psychological symptoms in dementia (BPSD): A European Alzheimer's disease consortium (EADC) study. Acta Clin Belg 2007;62:426-432.

[14] ¹⁴
Robert PH, Frans RJ, Verhey E, et al. Grouping for behavioral and psychological symptoms in dementia: clinical and biological aspects. Consensus paper of the European Alzheimer disease consortium. Eur Psychiatry 2005;20:490-496.

[15] ¹⁵
Hollingworth P, Hamshere ML, Moskvina V, et al. Four components describe behavioral symptoms in 1,120 individuals with late-onset Alzheimer's disease. J Am Geriatr Soc 2006; 54:1348-1354.

[16] ¹⁶
Jeste DV, Finkel SI. Psychosis of Alzheimer's disease and related dementias. Diagnostic criteria for a distinct syndrome. Am J Geriatr Psychiatry 2000;8:29-34.

[17] ¹⁷
Lyketsos CG, Rabins PV, Breitner JCS. An evidence-based proposal for the classification of neuropsychiatric disturbance in Alzheimer's disease. Int J Geriatr Psychiatry 2001;16:1037-1042.

[18] ¹⁸
Olin JT, Schneider LS, Katz IR, et al. Provisional diagnostic criteria for depression of Alzheimer disease. Am J Geriatr Psychiatry 2002;10:125-128.

[19] ¹⁹
Maertens K, Marien P, Vloeberghs E, et al. Behavioural and neuropsychological correlates of frontal lobe features in dementia. Psychol Med 2006;36:1173-1182.

[20] ²⁰
Shinno H, Inagaki T, Miyaoka T, et al. A decrease in N-acetylaspartate and an increase in myoinositol in the anterior cingulate gyrus are associated with behavioral and psychological symptoms in Alzheimer's disease. J Neurol Sci 2007;260:132-138.

[21] ²¹
Morana EK, Becker JA, Satlin A, Lyoo K, Fischman AJ, Johnson KA. Psychosis of Alzheimer's disease: Gender differences in regional perfusion. Neurobiol Aging 2008;29:1218-1225.

[22] ²²
Garcia-Allozaa M, Gil-Beaa FJ, Diez-Arizaa M, et al. Cholinergic-serotonergic imbalance contributes to cognitive and behavioral symptoms in Alzheimer's disease. Neuropsychologia 2005;43:442-449.

[23] ²³
Garcia-Alloza M, Hirst WD, Chen CPLH, Lasheras B, Francis PT, Ramirez MJ. Differential involvement of 5- HT1B/1D and 5-HT6 receptors in cognitive and non-cognitive symptoms in Alzheimer's disease. Neuropsychopharmacology 2004; 29:410-416.

[24] ²⁴
Pritchard AL, Harris J, Pritchard CW, et al. Role of 5HT2A and 5HT2C polymorphisms in behavioural and psychological symptoms of Alzheimer's disease. Neurobiol Aging 2008;29:341-347.

[25] ²⁵
Cryan JF, Kaupmann K. Don't worry 'B' happy!: a role for GABA(B) receptors in anxiety and depression. Trends Pharmacol Sci 2005;26:36-43.

[26] ²⁶
Miczek KA, Fish EW, De Bold JF. Neurosteroids, GABAA receptors, and escalated aggressive behavior. Horm Behav 2003;44:242-257.

[27] ²⁷
Engelhardt E, Laks J, Cavalcanti JLS. O sistema glutamatérgico e a doença de Alzheimer. Rev Bras Neurol 2003;39:5-20.

[28] ²⁸
Lanctôt KL, Herrmann N, Rothenburg L, Eryavec G. Behavioral correlates of GABAergic disruption in Alzheimer's disease. Int Psychogeriatr 2007;19:151-158.

[29] ²⁹
Garcia-Alloza M, Tsang SW, Gil-Bea FJ, et al. Involvement of the GABAergic system in depressive symptoms of Alzheimer's disease. Neurobiol Aging 2006;27:1110-1117.

[30] ³⁰
Guimarães HC, Levy R, Teixeira AL, Beato RG, Caramelli P. Neurobiology of apathy in Alzheimer's disease. Arq Neuropsiquiatr 2008; 66:436-443.

[31] ³¹
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-284.

[32] ³²
Barca ML, Selbaek G, Laks J, Engedal K. The pattern of depressive symptoms and factor analysis of the Cornell Scale among patients in Norwegian nursing homes. Int J Geriatr Psychiatry 2008;23:1058-1065.

[33] ³³
Skogseth R, Mulugeta E, Ballard C, et al. Neuropsychiatric correlates of cerebrospinal fluid biomarkers in Alzheimer's disease. Dement Geriatr Cogn Disord 2008;25:559-563.

[34] ³⁴
McKeith IG, Dickson DW, Lowe J, et al. Consortium on DLB. Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium. Neurology 2005;65: 1863-1872.

[35] ³⁵
Borroni B, Agosti C, Padovani A. Behavioral and psychological symptoms in dementia with Lewy-bodies (DLB): frequency and relationship with disease severity and motor impairment. Arch Gerontol Geriatr 2008;46:101-106.

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