Piecing the Puzzle: Understanding and Managing BPSD

Don’t Touch Me, I’ll Hit You!’

“Stop it! Don’t touch me! I’ll hit you!”?

The sound of glass shattering pierces through the house.

Thomas hurries down the stairs to the sound.?

He hears Wati, his maid, pleading, “Uncle, please calm down—”?

“I don’t want to calm down, don’t touch me! I need to escape!”

He traces the noise to the dining table.?

What he sees is a sight.?

Wati is cowering at the side, trembling in fear and shock.?

His 80-year-old father is standing on a chair, holding a broken glass plate with blood streaming down his hand.?

Bits of his dinner are mixed with bits of glass shards, plastered over the table, the walls and the window.?

His eyes filled with rage and bewilderment.?

His hair was messy, his white T-shirt unbuttoned, breathing heavily.?

“Don’t touch me! The police are coming to get me!”

Thomas is in shock.?

This is probably the third or fourth time seeing his father like this over the past year.?

Everyone around him marvelled at the retired accountant. His pleasant and calm demeanour.?

He had never raised his voice at anyone.

After much coaxing, Thomas managed to calm him down, get him off the chair, and drive him to the hospital to have his hand treated.

At the emergency department, the doctor at the hospital asked Thomas, “Has this ever happened before?”?

“Yes, 3-4 times in the past year. Doctor, is my father going crazy?”?

“Have you observed any other odd changes in his behaviour recently?”?

“Well, come to think of it, he has been forgetful lately… sometimes he forgets my name. He hasn’t been sleeping well either, but I always assumed it was because of old age,” Thomas says.?

The doctor furrowed his brow. “I think I should refer your father to a geriatrician, to run some tests and rule out anything.”?

“Okay, doctor.”

After a visit to the geriatrician, Thomas’ father was diagnosed with dementia. His outbursts were behavioural and psychological symptoms of dementia (BPSD).

Thomas’ father’s story is not uncommon.?

Sadly, 9 out of 10 individuals who are diagnosed with dementia are expected to have behavioural and psychological issues.?

Malaysia is expected to be an ageing nation by the year 2030, with 15% of the population aged 65 years and older.?

Currently, 8.5% of Malaysian adults have dementia, and the number is only expected to increase.?

What is Dementia?

Dementia is like a disease that affects how people think, remember, and act.?

It makes everyday tasks, like getting dressed or cooking, harder to do.?

People with dementia may forget things often, have trouble with their behaviour and find it tough to connect with others.?

This condition slowly gets worse over time, making it challenging for them to live on their own.

The most common reason for dementia is Alzheimer’s disease, which is responsible for about 60-80% of cases.

Who Is At Risk of Developing Dementia??

Risk factors include

• Increasing age – there is an increased risk in those above the age of 65 years old)
• High Blood Pressure?
• Diabetes Mellitus?
• Being overweight or obese (BMI >25.0 kg/m2 and >30 kg/m2 respectively)
• Smoking?
• A history of stroke?
• Leading a sedentary lifestyle
• A history of depression
• Social isolation

Behavioural and Psychological Issues of Dementia

The term “Behavioral and Psychological Symptoms of Dementia” (BPSD) refers to a range of non-cognitive abilities, often described as soft skills.?

These include emotional responses, social interactions, and other aspects of behaviour that are distinct from memory and thinking abilities.

BPSD can be categorised into these five broad aspects:

Other signs also include:?

Sleep disturbances

Having trouble sleeping (insomnia) and experiencing a reversal of the sleep-wake cycle, such as sleeping during the day and being awake at night.

Disinhibition?

The inability to control one’s impulses, emotions or behaviours. This can result in socially inappropriate behaviours, speaking impulsively or acting in a way without considering the consequences.?

For example, undressing in public or laughing at inappropriate times.?

Compulsive or repetitive behaviours

Some examples include the need to arrange things in a certain way, excessive washing of hands, counting steps or objects repeatedly with no purpose and more.?

The nature and severity can change as dementia progresses.?

What Triggers BPSD?

Just as Thomas experienced, it can be distressing for caregivers and loved ones to witness their family members behaving in a manner that is different from their usual selves.

Before considering BPSD, it is important to rule out other causes of their behaviour:?

• Physical abuse at home.
• Side effects of medication like antihistamines and opioids like morphine.
• Infections like lung and urinary tract infections.
• Constipation.
• Pain, which can either be acute or chronic.?
• Depression.

An easy mnemonic to remember is:?

4Bs

Bowel: When was the last time he/she had a bowel movement?

Bladder: When was the last time he/she urinated? Was there painful urination or blood in the urine?

Beverage: Is he/she thirsty or hungry? Have they been eating and drinking as usual?

Bottom: Are there any obvious signs precipitating the agitation, like an injury or pain??

Now that we have ruled out other potential causes of agitation, it is important to identify triggers and precipitating factors of BPSD.?

Changes in the environment can make BPSD worse, especially if an older person struggles to adjust to these changes.?

Here are some potential triggers:

• Moving to a new home or living space.
• Loneliness, especially after experiencing the loss of a loved one or a significant change in social connections.
• Changes or disruptions in daily routine and structure can be unsettling for individuals with BPSD.
• Loud and excessive, loud noises at home, like construction.
• A change in caregivers.
• Inadequate lighting in the living space, whether too dim or too harsh.

What Can Be Done?

It is important to first understand that behaviours are caused by dementia and not an intentional act of defiance/aggression.?

How Can I Avoid Triggers or Prevent Hostile Situations?

Communication?

• Talk calmly and slowly.
• Look at them when you speak and use a friendly tone and body language.
• Use simple words and short sentences.
• Don’t yell or argue; it can make things worse.
• Encourage them to share how they feel.

Distract

• Bring up good memories.
• Shift their focus to another activity, or move to a different space.?

Environmental Changes

• Ensure the home is safe by keeping dangerous items like knives and matches out of reach.?
• Reduce clutter to avoid accidents.
• Maintain good sleep habits and establish a consistent routine.?
• Use a visible calendar or clock to help with orientation.?
• When moving your loved one to a new living space or home, bring familiar items to provide comfort and familiarity.

Medications?

Unfortunately, dementia is an incurable disease.?

However, medications can help slow down its progression.?

Your doctor may prescribe medications for dementia that can also indirectly help manage BPSD. These medications can improve cognition.?

Your doctor may include antidepressants for signs of depression and antipsychotics for psychosis.?

Melatonin may also be prescribed for those with sleep disturbances.?

Your doctor will provide counselling and closely monitor your loved one for any side effects from the medications.

Help and Support for Family Caregivers

Caretakers who spend a large amount of time with elderly people with BPSD are at risk of stress and burnout.

Taking care of someone else is a noble responsibility, but it’s also easy to overlook your own needs in the process.

Therefore, it is important to take time off for oneself. Take up a hobby, prioritise your own physical and emotional well-being, or join a support group. A good support system can help you weather through the tough days.?

Learn to manage stress and adopt relaxation techniques.?

Most importantly, do not be afraid to seek help if needed.?

Ageing Well

Each elderly person experiencing Behavioral and Psychological Symptoms of Dementia (BPSD) needs individualised care plans because there’s no one-size-fits-all approach.?

Collaborating with healthcare professionals and caregivers to create a personalised plan can greatly improve their quality of life and independence.

If you notice any signs of dementia in your loved one, seek help right away.