BPSD

IPA Washington Consensus Conference: Defining Behavioral and Psychological Symptoms of Dementia (BPSD)

In the Spring of 1996, the International Psychogeriatric Association (IPA) convened a 'Consensus Conference on the Behavioral Disturbances of Dementia' at the Lansdowne Conference Center in the Washington DC area. The purpose of the meeting was twofold: 

• To review current knowledge on behavioral disturbances of dementia
• To reach some consensus of opinion in five critical areas
• Nosology
• Pathophysiology
• Diagnosis
• Treatment
• Research directions

Background

Why did IPA feel it necessary to convene such a conference? As the world population ages, the number of people who develop neurodegenerative disorders such as Alzheimer's disease (AD) will inevitably increase. The progressive cognitive impairment seen in AD leaves patients increasingly unable to care for themselves. As the disease progresses and as patients become more reliant on caregivers they are also prone to dementia-related behavioral disturbances which can range from merely annoying (such as repetitive questioning) to dangerous (such as hitting and pushing). These behavioral disturbances pose significant difficulties for family caregivers and often lead to early institutionalization of the patient. Until recently, concentrated research efforts into the origin and treatment of behavioral disturbances had been sparse and somewhat disparate; hence, the IPA Task Force on Behavioral and Psychological Symptoms of Dementia felt the need to seek some level of international consensus on what these disorders were and how they could best be investigated and treated. 

Methodology

To achieve a consensus, the Task Force convened a number of experts in the field from around the world and set them the task of reviewing and answering a series of targeted questions:

Nosology

• How prevalent are the behavioral disturbances of dementia?
• When in the course of illness do they emerge?

Pathophysiology

• What mechanisms contribute to the development of behavioral disturbances?
• What mechanisms account for the clinical and biologic heterogeneity of dementia?

Diagnosis

• What are the most effective approaches to diagnosis?
• What instruments and rating scales are most useful?
• What are the cross-national and cross-cultural aspects of instrumentation?

Treatment

• What are the most effective approaches to treatment?
• When should treatment be initiated and how long should it be continued?
• What are the benefits of treatment and the risks of not treating behavioral disturbances?
• Is a treatment for behavioral disturbances also a treatment for dementia?
• What role do issues of specificity and pseudospecificity play?
• How is the treatment of behavioral disturbances reflected in practice guidelines and regulatory requirements of different nations?

Research

• What are the most promising directions for research?

Of course, answering these questions is no easy task and their considerations produced much discussion and debate. A guiding principle throughout the discussions was that research findings should be synthesized into concrete concepts that have clinical application, wherever possible, so that clinicians can use the research to provide the best standard of care possible within their own local setting.

For the full text of the consensus group's statement in answer to these questions, click here: IPA Consensus Statement 

Conference Summary

• Conference participants recommended that the term 'behavioral disturbances' should be replaced by the term 'behavioral and psychological symptoms' because the term is difficult to define.
• Behavioral and psychological symptoms (BPSD) is defined as: 'symptoms of disturbed perception, thought content, mood, or behavior that frequently occur in patients with dementia'. 
• Symptoms can be grouped into psychopathologically recognized symptom clusters or organized by function or altered behavior. 
• The greatest opportunities for intervention and alleviation of patient suffering, family burden and societal costs are within the domains of these symptoms. 

• BPSD are integral elements of the disease process and are therefore a legitimate concern of healthcare workers worldwide.

Faculty

Sanford I. Finkel, MD, convened the conference. Barry Lebowitz, PhD, presented the initial statement of conference goals and objectives. Session topics and presenters are listed below. Special thanks to the session facilitators: Gene D. Cohen MD PhD, Jorge A. Costa e Silva MD and Norman Sartorius MD PhD FRCPsych, led by Sheldon I. Miller MD. 

Etiology

William Bondareff MD PhD, Carl-Gerhard Gottfries MD PhD, Witte J.G. Hoogendijk MD, Brian A. Lawlor MD, Lawrence, W. Lazarus MD, David L. Sultzer MD, Steven H. Zarit PhD, George S. Zubenko MD PhD.

BDD in Our Current Nomenclature System

Eric D. Caine MD, Peter V. Rabins MD MPH, Michael Zaudig MD.

Theory Behind Scales and Measurements

Louis Burgio PhD, Jiska Cohen-Mansfield PhD, Jeffrey L. Cummings MD, Serge Gauthier MD, D. William Molloy MB FRCP (c), Barry Reisberg MD, Trey Sunderland MD, Joan M. Swearer MD, Pierre N. Tariot MD, Linda Teri PhD.

Criterion Validity: Do the Symptoms Respond to Treatment Ð Pharmacologic and/or Nonpharmacologic?

Stefanie Auer PhD, Martin Brecher MD DMSc, D.P. Devanand MD, John S. Lyons PhD, Lon S. Schneider MD.

Clinical Perspectives: What Should We Be Studying?

Benny BrŠnnstršm DMSc RNT, Alistair Burns MD, Sture Eriksson MD, George T. Grossberg MD, Martin Haupt MD, Dilip V. Jeste MD, Jay S. Luxenberg MD, Karen Anne Ritchie PhD Mpsych, Barry W. Rovner MD, Burton V. Reifler MD MPH, Marco Trabucchi MD, Peter J. Whitehouse MD PhD.

What Aspects of BDD Are Important to Caregivers?

Henry Brodaty MD PhD, Carolyn York Cooler RN, Sunnie Kenowsky DVM, Astrid Norberg PhD.

Cross-Cultural Perspectives

Vijay Chandra MD, Hugh C. Hendrie MB ChB, Akira Homma MD, Carlos A. Mangone MD, Jacobo E. Mintzer MD

Research

Zaven Khachaturian PhD