The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on management of behavioral and psychological symptoms in dementia

Anderson Chen, MD

VA Boston HealthCare System
The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on management of behavioral and psychological symptoms in dementia

Scientific Abstract

Background: Dementia is estimated to affect over 5 million adults in the United States and this is projected to double by 2060 (1). BPSD encompasses a diverse range of symptoms and behaviors including screaming, calling out, verbal and physical aggression, agitation, apathy, sexual disinhibition, defiance, wandering, hostility, intrusiveness, repetitive behavior and/or vocalization, hoarding, nocturnal restlessness, emotional liability, paranoid behaviors, and psychosis (hallucinations and/or delusions) (2-4).

In this review, we update a 2013 algorithm (co-authored by two of the present authors, DNO and EM) focused on the role and use of psychopharmacological agents for treating these symptoms (3, 5). We expanded on the previous proposal of two algorithms (as originally suggested by Rajesh Tampi, M.D) to three: one for patients with “emergent” BPSD needing immediate help with agitation, one for “urgent” cases where agitation needs to be treated but may wait up to a few weeks for improvement, and one for “non-emergent” cases whose symptoms may be only moderately disruptive.

Methods: We reviewed the 2013 BPSD algorithm and conducted a systematic literature review on PubMed using Preferred Reporting for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (6).

Results: Patients with emergent BPSD where oral medication is not feasible, we recommend trying intramuscular injection (IM) olanzapine, then IM haloperidol, followed by possible consideration of an IM benzodiazepine, and then oral medications as presented in the urgent BPSD situation.

In the patient with urgent BPSD we recommend aripiprazole, then risperidone, perhaps next could then be prazosin, and lasty electroconvulsive therapy is a consideration. Lastly for patients with non-emergent BPSD, we recommend decreasing anti-cholinergic load and optimizing pain control, then optimize sleep (trazodone may be beneficial), then initiate donepezil and memantine, then trial of SSRI, and then antipsychotics as in urgent BPSD algorithm. At this point prazosin may be worth considering, and lastly we cautiously recommend carbamazepine.

Conclusion: This poster presentation’s objective is to offer what might be the most up to date and evidence supported psychopharmacological approach to BPSD treatment, considering efficacy, effectiveness, and safety.

Live Zoom Session – April 21st

research Areas

Authors

Anderson Chen M.D., Frank Copeli M.D., Eran Metzger, M.D., Alesia Cloutier D.O., David N. Osser M.D.