Behavioral and psychological symptoms of dementia (BPSD) present one of the most difficult challenges in the care of patients with dementia and are the major reason for the early institutionalization of these patients. Although antipsychotics have been used to treat BPSD, these drugs often induce adverse effects, such as extrapyramidal symptoms, falls, pneumonia and spiritlessness.1,2 In the USA, legislation has been introduced to regulate the prescription of antipsychotic drugs to patients in nursing homes.3 Although antipsychotic drugs were originally targeted at schizophrenia, they have recently been prescribed for BPSD because the symptoms of BPSD are similar to those of schizophrenia. There have been many reports of positive effects after the treatment of BPSD with antipsychotics.4,5 In Japan, there has been widespread acceptance of the use of antipsychotics to treat BPSD, because there are few other useful methods at present to control BPSD. Because of the similarity of the symptoms of BPSD and schizophrenia, we wonder whether there are also similarities in the pathogenesis of the two conditions and whether there are other useful methods available for the management of BPSD that do not rely on the prescription of antipsychotics.
HYPOTHESIS OF BPSD
Although we could not determine the pathogenesis of BPSD scientifically, we can speculate on the underlying causes of the symptoms of BPSD using psychological analysis. A typical BPSD is anger in association with violent language and physical violence. The anger is usually a manifestation of a patient's dissatisfaction with responses to his/her demands. The lives of dementia patients are severely disrupted because of the loss of memories of person, place, time, and circumstances and how to handle them, and the patients are often confused as to why they cannot live their lives as before. Patients get angry because they perceive they are not being treated properly relative to their expectations, although their expectations might be unrealistic. The patients might also feel angry with themselves as a result of their confusion and torment. Frequent ‘mishandling’ of these patients relative to their expectations might finally result in violence. The violence might also come about as a self-defense mechanism when the patient perceives that ‘strange’ people are getting too close (many patients with dementia no longer recognize their families). Dementia patients often demand to be taken back home, which is natural given their loss of orientation of place. Furthermore, dementia patients often claim that someone has stolen money from them, which is diagnosed as a delusion. Because these patients have lost memories of place and time, they are frequently disoriented and suspicious and thus believe that money that they once had has, in fact, been stolen. Some dementia patients report having recent telephone conversations with people who have died some time ago. This sort of illusion is likely to be a result of a misunderstanding of time. Dementia patients, especially those with Lewy body disease, often claim seeing a thief, small animals or dolls. These strange visions, often called delusions, might result from disturbances in the sight area in the occipital cortex. In addition, patients with dementia might mistakenly identify objects as a result of sight impairments. Wandering about outside or inside their homes might be the result of these patients searching for something they perceive to have lost in their lives. Patients with dementia might seem lost and wandering about madly, but they are only confused in terms of place, time and situations. Reversal of day and night is seen quite often in patients with dementia.6 Patients experiencing disorientation of place during the night might become very anxious, resulting in an additional reliance on caregivers. When the response of the caregiver is not sufficient to allay the patient's anxiety, the patient might communicate his/her frustrations by screaming loudly, which is diagnosed as delirium.
Although brain functions are complex and have not yet been completely explained, it has been confirmed that different brain regions are involved in different functions; for example, the neocortex is involved in cognitive functions and rational decisions, whereas the limbic system is involved in functions relating to instinct, demand, feeling and emotion.7 There is tight communication between the neocortex and limbic system, although they might be controlled independently. In aged people, control of the limbic system by the neocortex becomes weaker and the elderly often show ‘emotional incontinence’ and become excitable. Under pathological conditions of a decline in the functions of the neocortex, as in dementia, patients are more likely to show negative emotions associated with the limbic system, such as anger, excitability and anxiety (i.e. BPSD), because control of the limbic system by the neocortex has diminished. If the function of the limbic system is diminished, patients are likely to become apathetic, another type of BPSD. Together, these observations and speculations suggest that BPSD in dementia might be caused primarily by reasonable mistakes made by the patients rather than being of psychological origin, such as in schizophrenia.
ADVANTAGES AND DISADVANTAGES OF THE USE OF ANTIPSYCHOTICS
Although there are many reports regarding the use of antipsychotics in the treatment of BPSD and antipsychotics are widely used in clinical practice in Japan, many adverse effects have also been reported.8 The use of antipsychotics can be safe in most patients with BPSD if they are stopped when adverse effects appear. However, once they appear, the adverse effects of antipsychotics are often severe enough to cause pneumonia, falls and many other impairments that diminish a patient's quality of life and might even cause death. A recent study has reported that although antipsychotics decrease BPSD, they increase mortality.9 Furthermore, there has been an increase in lawsuits regarding medical treatment. Because the USA Food and Drug Administration has warned of the potential for accidents, in future antipsychotics might no longer be approved for the treatment of BPSD in Japan.3 The decay in blood concentrations of antipsychotics decreases by half when kidney function is decreased by 35%. In people over 80 years-of-age, kidney function has usually decreased by half. Therefore, an accumulation of antipsychotic medication and/or overdosing could easily occur. The use of antipsychotics improves BPSD, but simultaneously reduces brain function. Thus, even if antipsychotics improve the degree of BPSD, the reasons underlying the anger and/or any other symptoms would not have been addressed. When the degree of BPSD subsides, the burden on caregivers eases, but this does not necessarily translate to a similar benefit to the patients themselves, because the antipsychotics do not address the underlying causes of BPSD. Furthermore, patients who are being treated with antipsychotics tend not to respond to interesting stimuli or recreational pursuits and this might discourage caregivers. Thus, the use of antipsychotics might result in a ‘dehumanizing’ of dementia patients.
Patients who are not being treated with antipsychotics might sometimes have sufficient clarity of mind to thank their caregivers for the services they provide. Furthermore, families are often grateful that they can talk with patients about various things, although this sort of communication is not possible if patients are on antipsychotics. In normal healthy individuals, antipsychotics reduce cognitive function; in dementia patients, the use of antipsychotics can result in a further reduction in brain function and increased confusion. Thus, it would be preferable to reduce BPSD in dementia patients without further diminishing brain function by using antipsychotics and to address the reasons why patients are angry or show other BPSD. However, in many cases, this approach is not feasible. Thus, alternative treatments for BPSD in dementia patients need to be investigated and evaluated.
CARE FOR DEMENTIA PATIENTS THAT DOES NOT RELY ON ANTIPSYCHOTICS
Lavender aromatherapy has been shown to decrease BPSD very quickly and was effective over a long period of time.10 When the lavender aroma stimulated the smell sensor in the limbic system, patients forgot why they were angry and focused their attention on more interesting stimuli. Foot care with massage, which might stimulate the somatic sensor in the limbic system, has also been reported to decrease BPSD.11 Another way of reducing BPSD has been reported to be using a life-size doll to ‘hold’ patients;12 this most likely works by somatic stimulation of the limbic system. Caregivers often hold patients with dementia to relieve their anxiety. Patients with BPSD might feel reassured by being held in a similar way as children do when they are held by their mothers. Holding, but not restriction, could be one useful way in which to care for patients with BPSD. Creating a personal DVD that then screens a patient's favorite pictures and greetings from his/her family (including grandchildren) has also been reported to effectively reduce BPSD.13 Emotional stimulation of the limbic system has been reported to improve cognitive function;14 thus, non-threatening and comforting stimulation of the limbic system might be effective not only in reducing BPSD, but also for improving cognitive function in patients with dementia. Finally, in addition to antipsychotics, Yi-Gan-San, a Chinese herbal medicine,15 and azelastine hydrochloride, an anti-allergic medication,16 have been reported to be effective in improving BPSD. Treatment using a combination of stimulation of the limbic system and these alternative medications might be preferable in caring for people with BPSD rather than using antipsychotics.
Dementia patients might become angry when their claims are denied by their caregivers. Their anger might worsen if their pride is damaged. When caregivers deny a patient's claims, the patient might perceive that the caregiver dislikes them and that the caregiver is their enemy. Meanwhile, caregivers might also become frustrated because of the repetitive and endless nature of caring for a patient with dementia.17 It has been reported that the psychological strain imposed on primary caregivers is dependent on the nature of the family relationship with the dependent older person (i.e. good or poor).18 Caregivers may themselves become angry with the patient or sometimes maltreat the patient, which would accelerate the appearance of BPSD. Such negative symptoms of caregivers can be thought of as ‘behavioral and psychological symptoms of caregivers’ (BPSC). BPSC would further accelerate BPSD, creating a negative cycle. Sister Carmen has suggested that the mindset of care is particularly important for dementia patients and has put forward the following advice19:
- 1I want you to remember who these patients are.
- 2We treat them with the care and respect they deserve.
- 3They will open up to you only if you give of yourself first.
If the caregiver acknowledges a patient's claims, the patient will perceive that the caregiver likes them and supports them. This would enable an atmosphere of more friendly care for the dementia patients. Therefore, BPSD might either increase or decrease depending on BPSC (Fig. 1). Nobody wants to develop dementia, but most will not be able to avoid it because of the increased life expectancy.20 However, small pleasant feelings, brought about by small pleasant stimulation of the limbic system, are possible even in patients who have dementia, improving the state of mind in these patients. Under these circumstances, patients are more likely to express their gratitude to their caregivers, but this is unlikely to be seen if patients are treated with antipsychotics.