Factors associated with behavioral and psychological symptoms of dementia

Abstract

Most people with dementia suffer behavioral and psychological symptoms (BPSD). These symptoms add to caregiver stress and accelerate cognitive decline. The etiology of BPSD is complex, with multiple factors influencing symptom manifestation. The ability to accommodate and communicate needs decreases with cognitive deterioration. Unmet needs may explain why some individuals, despite having the same diagnosis and degree of cognitive impairment, have more severe BPSD. BPSD is treated with both atypical and typical antipsychotics (APD). Numerous studies demonstrated that APD treatment in individuals with dementia might cause major side effects, including death. The purpose of this Thesis is to examine factors associated with BPSD in a large group of individuals with dementia.

The Thesis covers four cross-sectional investigations using data from five Swedish registries: The Swedish registry for cognitive/dementia disorders (SveDem), the Swedish Behavioral and psychological symptoms of dementia Registry (BPSD registry), the Swedish Prescribed Drug Registry (SPDR), the Swedish Cause of Death Registry (CODR), and the Swedish National Patient Registry (NPR). Six types of diagnoses were included in the studies: Alzheimer’s disease (AD), vascular dementia (VaD), mixed (Mixed) dementia, Parkinson’s disease dementia (PDD), dementia with Lewy bodies (DLB), frontotemporal dementia (FTD) and unspecified dementia (UNS).

In Study 1, we discovered that 75% of individuals with dementia exhibited at least one clinically significant BPSD, the most prevalent being aberrant motor behavior, agitation/aggression and irritability. In comparison to AD, we found a lower risk of delusions (in FTD, UNS), hallucinations (FTD), agitation (VaD, PDD, UNS), elation/euphoria (DLB), anxiety (Mixed, VaD, unspecified dementia), disinhibition (in PDD); irritability (in DLB, FTD, UNS), aberrant motor behavior (Mixed, VaD, UNS), sleep and night-time behavior changes (UNS). Higher risk of delusions (DLB), hallucinations (DLB, PDD), apathy (VaD, FTD), disinhibition (FTD) and appetite and eating abnormalities (FTD) were also found in comparison to AD. In Study 2, pain was the most prevalent unmet need, followed by sleeping disturbances, impaired hearing and impaired vision. Additionally, we found that the risk of BPSD increases with unmet physical or psychological needs in dementia. In Study 3, APD use at the time of dementia diagnosis was associated with increased mortality risk across the cohort and by dementia subtype. In Study 4, we found that out of 53,384 individuals with dementia, 1,823 owned a firearm and 419 were unfit owners. Owners of firearms were mostly male, younger, living alone and without homecare support. Living with another person, frontotemporal dementia, APD and hypnotics prescription, being diagnosed in a memory/cognitive clinic, female gender, and mild and moderate dementia were the most important predictors of being reported to the police.

In conclusion, individuals with dementia who live in long-term care facilities frequently develop BPSD. Additionally, unmet needs are significantly associated with BPSD in each dementia type. Individuals with dementia receive both typical and atypical APDs, however, their use is associated with an increased risk of death. Finally, we found that the decision to withdraw the firearm is based on a variety of clinical factors associated with dementia.