Alzheimer's disease (AD) is a progressively developed neurological degenerative disease. In addition to the decline in cognitive function and living ability, patients often experience different degrees of mental behavioral symptoms (BPSD) during the course of the disease.
BPSD refers to the disorderly symptoms of perception, thinking, emotion or behavior that often occur in patients with dementia, including aggression, restlessness, hallucinations, mood swings, etc.; 90% of AD patients will develop BPSD, which puts huge pressure on disease treatment and family care. At present, BPSD has not been correctly recognized by the public and is often mistaken for a mental illness. The correct visit rate for AD patients is low.
BPSD related factors
Clear the relevant factors of BPSD in AD patients and play an important role in the prevention and improvement of BPSD.
- demographic data
1. The age of onset of BPSD
studies show that the severity of BPSD in patients is negatively correlated with the age when BPSD occurs, that is, the younger the age of onset, the worse the symptoms, and the most likely symptoms are behavioral disorders and day and night rhythm disorders. It may be because the younger the age when BPSD occurs, the earlier the AD disease is, that is, the disease develops relatively quickly, the brain lesions are more serious and the lesions are wider, so BPSD is also more obvious.
2. Disease course
AD patients' course of disease on patients' BPSD is mainly reflected in the severity of BPSD and the symptoms that appear. In terms of the severity of BPSD, the longer the disease period and the more serious the dementia, the more BPSD it will appear. Studies have shown that as the patient's age or age of onset increases, AD patients experience symptoms of delusion and behavioral disorders more frequently, and BPSD is obvious. From the perspective of BPSD that occurs, as the disease develops, the frequency of depression symptoms in dementia patients decreases, while the incidence of agitation and aggressive symptoms increases.
3. Gender
Research found that compared with female patients, male patients are more likely to experience wandering, insulting and improper behavior. Female AD patients have more severe depression symptoms.
4. Pre-onset personality
study found that pre-onset neurotic personality is significantly related to the total score of the patients' neuropsychiatric scale and anxiety status, and the lower affinity is significantly related to the patients' irritability and anxiety. However, the correlation between lower affinity and BPSD is stronger than premorbidity neuroticism.
2 Living and environmental factors
1. Living habits
Poor living habits are risk factors for AD. Studies have found that compared with AD patients with Amateur preferences before the disease, AD patients with Amateur preferences before the disease have significant BPSD. AD patients who are forced to quit drinking after
After the disease, they are more likely to develop emotional disorders, anxiety and fear.
2. Life events
Research shows that pre-onset life events (such as spouse/child accidents, impaired health functions, etc.) affect the occurrence and seriousness of BPSD, and are prone to cause emotional symptoms such as depression and anxiety and aggressive behaviors.
There are personal emotional problems before the onset of the disease at the same time and is also a risk factor for the occurrence of BPSD. It may be because what happened before the disease caused a certain impact on the patient's emotions, causing AD patients to induce relevant BPSD during the disease.
3. Self-care ability
Studies have found that the damage to cognitive and daily life abilities of AD patients is significantly related to the patients' BPSD. That is, the lower the self-care ability of AD patients, the lighter their BPSD performance. Some studies have further found that BPSD, especially hallucinations, behavior disorders, day and night rhythm disorders, and impaired self-care ability.
4. Temperature
Climate change has an impact on BPSD in AD patients, that is, the higher the temperature, the more serious the behavioral symptoms of AD patients.This may be because climate changes can make people feel uncomfortable, dementia patients have more obvious discomfort responses caused by environmental changes due to deterioration in response to environmental changes, or the increase in ambient temperature increases the body's nuclear temperature and brain temperature, causing an imbalance in the body's temperature regulation system, which triggers a series of behavioral symptoms.
3 Disease factors
1. The degree of cognitive impairment and family history of mental illness
The degree of cognitive impairment is different, and the BPSD appears different. Patients with mild Alzheimer's disease often experience irritability, while patients with severe sex are prone to wandering, indifference, persecution and identification errors.
Different studies have found that the incidence of hallucinations and severe levels of patients with severe cognitive dysfunction are higher than those of mild and moderate patients. Therefore, some domestic scholars have proposed that the occurrence of hallucinations should be used as a warning factor for the severe level of dementia in AD patients. Patients with a family history of psychiatric disorders may be more likely to develop BPSD, and studies have found that family history of psychiatric disorders is a risk factor for all BPSD except depression, anxiety, and sleep disorders.
2. Metabolic syndrome (MS)
It is now known that certain risk factors in MS are related to the occurrence of AD. Studies have shown that the risk of AD in MS patients is 3.2 times that of patients without MS. At the same time, studies have found that the incidence of MS in AD disease group is significantly higher than that in healthy people. Further research found that compared with the non-MS group, the detection rate of delusion, agitation and irritability in the MS group was higher.
3. Leukoencephalopathy
Research found that most patients with BPSD have more serious leukoencephalopathy. Compared with patients without BPSD, patients with BPSD have more serious leukoencephalopathy. Studies have proved that high cerebral white matter is a reliable marker of cerebral ischemia, so optimizing vascular risk factors can be used as a strategy to reduce the severity of BPSD in AD patients.
4. Hyperhomocysteinemia (HHcy), lack of folic acid and vitamin B12
homocysteine (Hcy) concentrations are affected by folic acid and vitamin B12. Insufficient folic acid and vitamin B12 will cause the increase in the concentration of Hcy in the body and form HHcy. HHcy has been confirmed to be a risk factor for AD and is related to the severity of BPSD.
BPSD clinical management principles and methods
Management principles
BPSD management should follow the principle of individualization and run through the entire course of dementia, that is, from prevention during the asymptomatic period to intervention in severe behavioral disorders. The goal is to reduce or alleviate the intensity or frequency of symptoms, the burden on caregivers, and improve the quality of life of patients and caregivers. Based on the use of anti-dementia drugs, non-pharmaceutical intervention is preferred in clinical practice. Drug treatment is only used when non-pharmaceutical intervention is ineffective or BPSD seriously affects the patient's life, affects treatment compliance, makes it difficult for the patient to obey care, or has emergencies or safety problems.
1 Drug treatment
1. Anti-dementia drug
Anti-dementia drug can not only improve cognitive function or delay cognitive decline in patients with dementia to a certain extent, but also have a certain improvement effect on some mental and behavioral symptoms.
cholinesterase inhibitors, such as donepezil , cabalatine , galantamine , and galantamine have good efficacy on hallucination, indifference, depression and other behavioral symptoms in dementia patients; N-methyl-D-aspartate receptor antagonists, such as memantine, have a certain effect on agitating and aggressive behavior in patients with severe dementia.
When non-pharmaceutical intervention and anti-dementia treatment are ineffective, or when encountering the following serious and urgent situations, it is recommended to use psychotropic drugs in combination:
(1) The concept of serious depression with or without suicide;
(2) The psychotic symptoms that cause harm or have great harm;
(3) Attacking behavior that poses risks to oneself and others' safety.
should be continuously monitored when treated with psychotropic drugs. It is recommended to regularly consider whether the dose can be reduced or the medication can be stopped every once in a while (such as every 3 months).
2. Antipsychotic drugs
The second generation of antipsychotic drugs are effective in part of mental behavioral symptoms, and their efficacy evidence is relatively strong. Although the US FDA issued a black box warning for the use of second-generation antipsychotics and first-generation antipsychotics for BPSD, second-generation antipsychotics can still be used for patients with moderate- and severe dementia when BPSD is severe and other effective treatments are lacking.
clinicians need to weigh the benefits of treatment with the risks of adverse events in . They should follow the small dose starting and use according to the principle of slow and gradual increase in adverse reactions.
3. Antidepressants
such as serotonin reuptake inhibitors, etc., have limited efficacy on depressive symptoms in patients with dementia. citalopram may be expected to be used for the treatment of symptoms of dementia agitation, but the QT interval needs to be monitored during the treatment process.
4. The efficacy of mood stabilization drug
valproate on impulsive and agitated behaviors still needs further systematic research.
2 Non-drug treatment
Non-drug intervention emphasizes people-oriented. The adoption of non-pharmacological interventions may greatly promote coping and improving functions, increasing social and physical activities, increasing intelligent stimulation, reducing cognitive problems, dealing with behavioral problems, resolving family conflicts and improving social support. Non-pharmaceutical intervention methods for AD patients include environmental therapy, sensory stimulation therapy, behavioral intervention, music therapy, soothing therapy, fragrance therapy, recognition therapy, cognitive stimulation therapy and other forms. In addition, supportive interventions for caregivers are equally important. In particular, individualization characteristics should be paid attention to when formulating and implementing non-pharmaceutical intervention technologies.
3 Professional care and caregiver support
Multidisciplinary team collaboration with professional care quality is closely related to the management of BPSD. It is recommended to include caregiver education and support in the routine work of BPSD management, including providing them with training on stress reduction or cognitive remodeling techniques, guiding special skills in managing behavioral symptoms, strengthening communication with dementia patients, improving the family care environment, etc.
References:
[1] Zhu Nannan, Zheng Mingming, Li Jingwei, Chen Yuanyuan, Cheng Peng, Zhang Xulai. Investigation and research on mental behavioral symptoms and influencing factors in patients with Alzheimer's disease [J]. Neurological damage and functional reconstruction, 2022, 17(04): 231-233.
[2] Ge Gaoqi, Wang Jingjing, Qi Chong, Zhang Xiumin, Gao Yuxia. Research progress on factors related to behavioral and mental symptoms in patients with Alzheimer's disease [J]. Chinese Journal of Geriatrics, 2017, 37(02): 507-509.
[3] Geriatric Psychiatric Group, Psychiatric Branch of the Chinese Medical Association. Expert consensus on clinical diagnosis and treatment of mental behavior symptoms groups in neurocognitive impairment [J]. Chinese Journal of Psychiatry, 2017, 50( 5): 335-339.
Edit | Dan Tai Yiran reviewed | Dong Xiaohui
