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Psychiatric News Special Report: Evidence-Based Management of Behavioral Symptoms of Dementia · The Medical Mind

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Yeah.
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All right, everybody. Welcome back to Psychiatric News Special Report August 2026
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podcast. We are having a great discussion today with Dr.
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Rajesh Tempi. This is his article that he just he came out for the special report.
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It's evidence based management of behavioral symptoms of dementia.
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I'm the host for the show, Dr.
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Sulman Aziz Mirza Triple Board Certified Adult Psychiatry,
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Child Adolescent Psychiatry.
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Addiction medicine. And this article to me is a reminder
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of why I went into become primarily a child and adolescent psychiatrist.
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~ this is the opposite spectrum of what I normally work with on a day-to-day basis.
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But it's something that I think a lot of people,
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maybe in my shoes are not, in regards to don't want to think about it,
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you know, as hard as like.
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Sometimes as a psychiatrist, to be like,
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do I want to be working with dementia patients?
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Is it a a helpful? How much help can I be for a lot of caregivers?
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It is definitely a huge, huge burden,
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perhaps. And then of course, the people who are going through it themselves,
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like it's obviously very, very difficult.
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~ so again, like we have Dr. Rajesh Tampi with us here.
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He is the author, one of the authors for the paper.
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~ Dr. Tampi, welcome to the show.
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How are you doing?
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Thank Dr. Brazil. Thank you. ~ glad to be here talking about
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a very important problem in geriatric psychiatry,
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but that is behavioral and psychological symptoms,
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also known as neuropsychiatric symptoms of dementia.
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Yeah. Tell us a little about yourself,
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your background, and what what led you to put this article out for us.
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Yeah, so you know, I'm I'm a boat certified geriatric psychiatrist.
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I'm the past president of the American Association for Geriatric Psychiatry
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and its inaugural historian. ~ in my day job,
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I am the chair of psychiatry here at Creek Medical School in Omaha,
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Nebraska. ~ So why is it important?
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Because you know, we are an aging society.
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You know, the for the first time ~ in the history of the world,
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we have more people ~ above the age of sixty-five than under the age of five.
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~ by 20 ~ thirty-five we will have more individuals over the age of sixty five than
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under the age of eighteen. So other than being a child psychiatrist
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or a pediatrician, ~ you are going to be dealing with ~ these kind
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of individuals because most of the patients that you see in hospitals ~ are older,
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~ they have polymorbidity, they may have neurocognitive disorders,
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and and ~ behavioral symptoms are in built into the natural history.
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~ of the dementing process. So ~ this is not very separate from
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the cognitive issues. This is inbuilt into that.
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And as we discuss you will c it'll become much more clearer to you.
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Yeah. So one of the things when I was going through again,
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like I'm primarily a child adolescent psychiatrist,
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when I'm reading the article and you kind of briefly touched on it the
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the the scope of the issue. So some of the prevalence numbers,
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I guess like a third of community dwelling patients are gonna have some
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of these concerns. Eighty percent of those in nursing home are gonna have these
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concerns, ninety percent will develop these.
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disorders during the course of the illness,
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right? So it's
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Ninety percent or more. Yep, so yeah,
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yeah. So as what we know is that,
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you know, so first of all, you know,
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people misunderstand dementias or what now in the DSL five TR or the
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DSM five and the DSM five TR we call us major neurocognitive disorders.
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So these are neurocognitive disorders.
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You're not these are not memory disorders alone.
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So you know, people misunderstand.
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So memory disorder is amnestic disorder,
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whereas dementias are much more than that.
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So they have cognitive decline.
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and then they develop functional decline and then behavioral symptoms
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can emerge at any time during the life history of the illness.
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That's why over ninety-seven percent will ha or will have over ninety percent
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~ will have these behavioral symptoms sometimes during the course of
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the ~ the illness. But it may be the first sign that the patient
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is having a neurocognitive disorder.
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So it may be the heralding sign.
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So ~ you know people may become apathetic.
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That means they're withdrawn, ~ not initiating activities.
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~ so not interested in doing anything that ~ may be per misperceived
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as being depression but the underlying issue is the neurocognitive disorder
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so it it can happen at any time and the magnitude ~ you know ~ we have
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~ number of individuals who are older now probably 45 million individuals over
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the age of 65 and that number is going to s ~ rise significantly
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and almost double in about 20 to 30 years.
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And ~ a significant number of these individuals will have cognitive issues because
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neurocognitive disorders are more common as people age.
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So age is the number one non-modifiable risk factor for these disorders.
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So as this population ages, more individuals will ~ have neurocognitive disorders.
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~ 30% of individuals over the age of 90 will have ~
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you know neurocognitive disorders.
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Centenarians, 75% will meet the clinical criteria.
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So the numbers are large.
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~ and then these are ~ quite important because they not only ~ as
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you read through the article you realize that they not only ~ increase morbidity,
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they increase mortality rates,
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cost of care, ~ burnout for the caregiver.
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So it adds to the complex complexity and the magnitude of caring
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for these individuals. So it's not simple.
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~ it's important, we all need to know about it.
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~ and then you know, as science progresses,
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we will have
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medications or group of medications that will help slow down
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the progress progression of illness.
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And now newer medications are coming out,
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you know, some medications that are being repurposed ~ for treating these behavioral
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symptoms. So I think it's important as a as a health healthcare provider
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to know about that. So at least you can ask for help.
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I think it's really important.
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One of the things that you mentioned was that sometimes that behavioral symptoms
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are the heralding symptoms. Like the first thing that we see ahead
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of sometimes the cognitive decline.
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I think there's a lot of focus in healthcare and in the media about like,
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~ cognitive deficits and grandma's losing her memory and grandpa's,
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you know, not the same as he was before.
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But I think the thing that really gets people into
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It's family is really involved as like when we have the behavioral symptoms more
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so than anything else. So
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So behavioral symptoms are you know a third of the cost of caring
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for individuals with neurocognitive disorders is because of behavioral symptoms.
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The most common is, of course,
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the functional decline. The issue is that caregiver ~ the behavioral symptoms
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not only affects the individual,
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but it affects the whole ecosystem around that individual.
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caregiving becomes a caregiving career because people with dementia
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and neurocognitive disorders are now living much longer.
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Decade. So people who are caring for them are also aging.
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So what happens is the it adds to the burden of ~ caring for those individuals.
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And the caregiver burden leads to worse outcomes for the caregivers themselves.
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They become depressed, they have more cardiovascular morbidity.
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~ So you really need to take care of these individuals around them.
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And when it is the heralding sign of the neurocognitive disorder,
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you may have you have may have to deal with these symptoms for.
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decade two decades so it is really long haul ~ and you really need to know
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how to manage them. ~ you know there are what is called the A,
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the B and C's of neurocognitive disorders.
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A is the activities of daily living B is the behaviors and C is the cognition.
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The cognition declines ~ functional functional the activities
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of daily living decline and then behaviors can emerge at any time.
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So when you are seeing an older patient in your clinic
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you should be cognizant of those three facts.
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~ so whenever you're seeing a patient for depression,
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if they're older, you also have to say,
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okay, how is your cognition? How's your functioning?
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~ are there any things because the depression that you're seeing may
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not be the depression per se. It may be the depression occurring because
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you the neurobiology of the brain is changing and you're now starting
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to have the neurocognitive cell.
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~ but because you know we have such short time to assess patients,
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everybody just treats what is right
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in front of your eyes, but they don't work up the patient properly.
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Yeah, which is an important important ~ point that I always kind of t you know,
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bring up is that the healthcare system environment and kind of
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the pressures that are out there,
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especially now of us, ~ that makes it really hard to kind of do that thorough,
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thorough, thorough evaluation.
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Correct. Which which I thought was again another interesting part of
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the paper was that, you know, again,
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going back to my residency training last time I was really working with
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patients with dementia directly as as you know as a as a provider was
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you it becomes like this algorithmic knee-jerk step.
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So you hear dementia, you hear agitation,
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you go antipsychotic. And you you hit them with some Haldol or you
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him with some Lanzine or you do something like that and boom,
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that should take care of it. And it's like we know that's not
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the the best treatment. So talk to us a little bit,
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you know, I I I really like that there was a
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kind of almost like a hidden not a hidden,
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but like a you know, the bio, psychosocial,
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environmental plan that we have to put in place for how we manage this.
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So talk to us about that a bit.
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So the yeah, so the important thing,
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that's a very, very important point that you bring up is that the one size does
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not fit all. ~ and I think we are we're so busy in the numbers of patients that
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we see and generating RVUs, you know,
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I think we have lost touch with what's the real ~ problem,
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the patient sitting in front of us.
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It's a human being, ~ it's a family member who's suffering.
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We need to really alleviate suffering.
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you know, I always have this pet be when people call me a provider.
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I I'm not a provider, I'm a healer.
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More than anything else. I heal.
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You know, I don't prescribe. I do what is the appropriate treatment
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for that particular condition.
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So I think taking the time ~ to s evaluate these patients appropriately
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is an important thing. So first and foremost,
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what should we do if a patient is sitting in front of you?
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That's the question that you know whether you're a child psychiatrist
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or forensic psychiatrist, if you have an older patient sitting,
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you're you're you're going to take care of them.
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First and foremost, history. You have to get information from the patient
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if they're able to provide it.
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And also from a knowledgeable source,
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~ a collateral source, who knows then it's a caregiver,
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it's a family member, it is a physician,
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it's a nursing homestaff, whoever it is.
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And then you have to see has there been a decline in cognition from
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the previous level of functioning?
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So that's what ~ dementia are acquired illnesses.
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So the cognition in these individuals declines over the course of their lifespan,
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which is different from intellectual disability,
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you know, kinds patients that you will see,
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you might see in your clinic. These are
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These people have cognitive deficits at birth and they remain static.
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And as they grow older, they may have greater risk for dementia.
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But in dementia, these people have normal cognition and then it declines
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as they age because of many reasons:
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biological, psychological, social,
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all of them mixed together. So,
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first and foremost, you have to get a good history,
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see if there is a decline in cognition,
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then find out if there is a decline in function,
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and then see if there are behavioral symptoms that emerge.
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And you have to do a good psychiatric history anyhow.
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Do these people have
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Previous psychiatric problems.
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I mean, because depression, anxiety,
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~ post-traumatic stress disorder,
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schizophrenia, bipolar disorder,
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all of them are risk factors for developing dementia.
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~ So you need to rule out psychiatric illnesses.
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Then you need to rule out medical illnesses.
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Are these people having any medical illness?
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A history of cerebrovascular accident increases the risk of dementia.
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~ History of Parkinson's disease increases the risk of cognitive decline.
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Hypothyroidism increases the risk of cognitive decline.
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Rolling out medical costs. Medications,
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you know, many of these medications that older people take,
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including the antihistamines, the benzodiazepines,
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the pain medications, can hasten the onset of cognitive decline.
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So a good medication reconciliation.
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Then do a good mental status examination to rule out or rule
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in whatever you're suspecting is going on.
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And then ~ a mental status examination with a cognitive evaluation
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and screening tools. And most of the screening tools like the
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Montreal cognitive assessment,
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the mini mental state examination,
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~ the St. Louis Mental Status Examination.
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These are all screening tools.
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They're not diagnostic in themselves.
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They tell you if the individual has a cognitive issue and is it below
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the norm for what, you know, for that age for that patient.
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And then, of course, you have to do a medical workout,
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do the lab work, ~ order MRI scans if needed,
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order a PET scan if needed. And then also if you're in doubt.
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You know, if you're not sure what's the issue,
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you or in neuropsychological testing.
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And I always say this in all my lectures is that in my ~ in my ~ area,
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neuropsychological testing is the best bag for the butt.
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what it does is it helps you differentiate between normal aging versus
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neurocognitive disorders. It tells you differentiates between
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the different etiologies for neurocognitive disorders,
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whether it's Alzheimer's disease,
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vascular disease, you know, frontal temporal lobo degeneration,
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dementia with low bodies.
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And then it also can differentiate between depression-associated dementia.
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We used to call this that you know depressive pseudo dementia.
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There is nothing pseudo about it.
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You know, the the changes are transient,
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but the changes are very real.
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~ and versus ~ you know, a new neurocognitive disorder or progressive dementia.
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So it that is the workup. So you have to do all of these steps.
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And the thing is, prescribing an antipsychotic medication,
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you know, is I I think a is a major mistake because.
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The agitation may be underlying a pain.
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You know, patient may be in pain.
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The patient may be constipated.
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So that is actually going to make the situation worse,
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not better. So I think we need to we need to be a little more cognizant,
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rule out the etiology, whether it is primarily due to an underlying medical
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or psychiatric condition, or it's a primary neurocognitive disorder,
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and then decide, okay, is this depression,
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is this ~ agitation, is this you know psychosis?
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And then
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treat or prescribe appropriately.
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And we are now starting to have medications which are helping
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us differentiate and appropriately treat those things.
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You know, like break preposol is an atypical antipsychotic,
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which you can use for agitation.
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Then now we have ovulity, they have an indication for treating ~
15:31
you know agitation and Alzheimer's disease dementia.
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So you're starting to now have repurpose medications for this condition.
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And I think you will have many more of those medications coming into the market.
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Which
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You w you you use when you've you non-pharmacological management,
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you know, like redirection, reminiscence therapy,
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pet therapy, music therapy all are primary because they help
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minimize the use of medications.
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And then you adjunct as an adjunct,
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you can use medications when those non-pharmacological managements have
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not been affected. So that's that's the basic algorithm I go through every patient
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when I see them.
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So when yeah, I I I really liked another kind of like takeaway from when
16:17
I was reading was that behavior is a communic is a form of communication.
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Absolutely. Right. ~ so with that,
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like in in like we said, there's behavioral symptoms,
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symptoms will often fluctuate.
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The cognitive symptoms are usually pretty steady,
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kind of decline. How when we're working with families or again,
16:39
even clinically, like how do we shift from going to
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How do I stop this behavior to what is the behavior trying to tell us?
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I think you were touching upon it a little bit there with yeah.
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So the the the thing is that the like ~ in the article it says that
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the behavioral symptoms are not consistent and they were fluctuating.
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~ you know, psychomotor agitation is the most persistent,
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but in Alzheimer's disease, ~ apathy is the most common symptom.
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So again, what you need to do is tell patients that ~ patients
17:07
and their families that there is no one medication fixed for all of this.
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So that is why a good initial evaluation with regular follow-up with
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the patient and their family members is the key to that.
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So
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Don't fire and forget. Don't just give one medication and then expect
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all the behaviors to be treated.
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And you know, you would see that often.
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You know, somebody has prescribed an antipsychotic and the symptoms have completely
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gone away, but the patient is still taking the medication two years down the line.
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You know, it increases the risk of cardiovascular or morbidity and mortality,
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cerebrovascular morbidity and mortality.
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So why do that? So regular follow-up.
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~ if you're in it depends upon where you are,
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if you're in the community.
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You know, every every ~ four to eight weeks if you see the patient,
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at least have phone contact with them in between just to help them through that
17:56
time. If you're in a nursing home,
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~ you know, usually it's once a week.
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If you're in a assistant living,
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once every week or every couple of weeks.
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So right, good evaluation with good cadence of follow-up,
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I think is the way way to treat these individuals because symptoms may
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not be there consistently, but different symptoms may emerge.
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You may have psychotic symptoms for a few months.
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then you may have anxiety, then they may have depression.
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~ you know, so y one medication is not going to fix all of them.
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Based on what you're what you've done,
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kind of what you've seen over over the years,
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and and again you mentioned a whole bunch of other things that it
18:35
can be besides like pure dementia,
18:37
but what are the most commonly missed kind of contributors that are out there?
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And then how often is the agitation more an underlying medical condition that people
18:50
are not understanding or not or seeing not seeing it?
18:53
So, important thing, like we talked about in the beginning,
18:56
there are the A, the B, and C's of neurocognitive disorders,
18:59
right? So the behaviors can emerge at any time.
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And the behaviors can be either primary,
19:04
that is inbuilt into the natural history of the dementia illness because
19:09
of all the neurobiological changes that are happening,
19:11
or they may be secondary due to either a psychiatric condition
19:15
or a medical condition. And history is going to help you ~ you know,
19:19
find hone and on what
19:20
Is exactly going on. So talk with the family members,
19:23
reviewing the chart, doing lab work will tell you,
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okay, this may be why the patient is agitated.
19:28
Like I said earlier, constipation,
19:30
pain, urinary tract infection,
19:33
pneumonia, ~ you know, ~ can all cause these symptoms.
19:37
So getting a good history, deciding on which is the which is the etiology,
19:43
the primary etiology, trying to address that,
19:45
and then closely watching and following up,
19:48
doing rating scales to
19:50
you know, quantify and qualify those symptoms.
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And then if there's no improvement,
19:55
going back to the drawing board and saying,
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okay, what am I missing here? Is this something else that is going on?
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And I think having a good high suspicion for an underlying medical
20:05
or a psychiatric etiology, I think will help us minimize unnecessary prescription.
20:09
That's what you want to do. You know,
20:11
~ remember ~ most of older adults ~ use polypharmacy.
20:15
That means more than five medications at any given time.
20:18
Many of
20:19
These medications are probably not prescribed over the counter.
20:23
And then if they're prescribed,
20:24
they're probably prescribed without an appropriate indication.
20:27
So you know you have this complex problem ~ with when you're dealing with them.
20:31
And people double up on their medication.
20:32
did I take my medicine today? I forgot.
20:35
So then they double up or they forget to take it.
20:37
So you have to walk through all of these things and make sure that
20:41
the ~ the prescription is being monitored.
20:44
how often are secondary conditions?
20:47
I think in about ~ these individuals,
20:49
about forty to fifty percent of the time,
20:51
the agitation may be second ~
20:53
Yeah.
20:54
to different conditions. So suspicion for those is are very important.
20:59
Yeah, it's it's not an insignificant amount.
21:01
You know, again, like you're saying,
21:02
just about half of the time almost that that is a contributing ~ cause of
21:07
it or the origin of the cause.
21:09
So pivoting a bit,
21:12
so like talking about care management,
21:14
I know you talked a bunch about the non-pharmacological care.
21:19
~ before kind of jumping into reviewing those ones a bit,
21:24
why do you think that
21:27
These non-pharmacological care receives less attention than the medicines.
21:33
Is it all just big pharma telling us to do this?
21:35
No,
21:36
you know, I I I you know, I I I I I I I I would move away from that political
21:40
debate. For me, the the our colleagues in the pharmaceutical industry are very,
21:45
very important to us. You know,
21:47
these are expensive medications,
21:49
they take a long time to develop,
21:51
there's a lot of investment that goes in,
21:53
and the trials are done with good intention.
21:56
You know, how people interpret that is completely different.
21:59
So, you know, I that's why every month I do a critical appraisal and we publish
22:03
as a psychiatric ~
22:05
~ times looking at each of those studies because for me a good systematic review
22:12
of the data is important you know people may say misinterpret but data doesn't
22:17
lie you know the data can be used differently so I would move away from that
22:20
political debate the reason why non-pharmacological management is so difficult
22:25
to do first of all it is time intensive it takes a long time two
22:30
it is labor intensive you know you need people to do it three
22:34
They they ~ the ~ to get that effect,
22:38
you need a whole village to be working around it.
22:40
So because of the logistics, it's just not feasible to do.
22:44
So I think they are great when you have them available.
22:48
And if there are dedicated family members or dedicated ~ nursing home
22:53
~ staff who are interested in doing it,
22:55
the outcomes are great. But in a situation where there is an aging caregiver
23:00
who really cannot do all of those kind of things.
23:04
Then it becomes important for us to understand that.
23:06
You know, giving it to somebody who just cannot do it is not going
23:09
to work because they're not going to apply.
23:11
So what I do is I tell them that every interaction
23:14
is a non-pharmacological management.
23:16
Even a normal conversation. You know,
23:18
if the patient is forgetful, getting into a heated debate about something that
23:23
person cannot remember is only going to agitate them.
23:25
So the thinking and the feeling parts of the brain are different.
23:29
Although they are connected, they may not always be connecting in
23:32
a person with neurocognitive.
23:33
Disorder. So what happens? The the the in ~ the input comes in through the thalamus,
23:37
goes into the amygdala and the hippocampus,
23:39
and people get fired away, they're irritated,
23:42
they're annoyed, their blood pressure goes up,
23:44
but their frontal cortex cannot tell them,
23:47
hey, this is not a threatening situation.
23:49
So calm down. You know what happens in PTSD?
23:52
Same thing. People react and then the agitation remains.
23:56
So I always tell caregivers patience is a virtue.
23:59
You know, if the if the individual with neurocognitive disorder
24:02
is saying something that is rude,
24:05
inappropriate, agitated, brush it off.
24:07
Roll with the punch. Don't take it to heart.
24:11
It's not that is not the person saying it,
24:13
it's their illness topic. So understanding is,
24:17
I think, the biggest thing. And clear evidence suggests education is
24:22
the center of non-pharmacological management.
24:24
A well-educated caregiver or a well-educated staff.
24:28
Is worth their weight and hold because they will roll with what is happening
24:33
and not take it to heart and not further distress and not engage in those kind
24:37
of things. So if somebody's saying something rude,
24:39
talk about something else. That's part of redirection.
24:42
If somebody is like agitated and wanting to push out of that,
24:45
distract them. Hey, look over there.
24:48
What's happening? So those are very simple things.
24:51
So education is one thing. So I do a lot of social prescribing with
24:55
my caregivers of eight.
24:57
I know it's difficult, I know it's hurtful,
24:59
I know you want you want to cry when this happens or say something,
25:03
it's not gonna help the situation.
25:05
So our goal is to redirect and then see how we can calm the person down.
25:10
~ of course, then you know if it's too difficult to deal with and
25:16
you know they're causing impairments in the person's life or safety issues,
25:19
then of course medications are what you want to do.
25:21
And again, for medications, it is start low,
25:24
go slow, don't keep on going.
25:26
because you don't use the same doses as you would do in a young adult because
25:30
the physiology is not the same.
25:32
The older patient is gonna react ~ much worse than a younger patient.
25:37
You know, I've seen people giving ten milligrams of a lancepine for
25:40
an older frail person. That's just gonna cause more damage than than
25:46
And just to clarify, I tease a little bit here and there with the joke.
25:50
So I know I know very similarly when we're talking about again on
25:54
on my age patients, in regards to like kiddos on the autism spectrum.
26:00
Again, I I would love to avoid prescribing medications and I would love
26:04
to have all the services in place.
26:07
You know, the ideal school for them,
26:09
the, you know, a therapist, a trained therapist,
26:12
an experienced.
26:13
registered behavioral therapists,
26:15
RBTs that may be with them and spending time with them and really making those
26:19
changes around them. But we didn't just like what you're saying is
26:22
we just don't have staff, right?
26:23
We just don't have the manpower.
26:25
We just don't have the ability.
26:26
You know, parents at times are getting assaulted by the the kiddos
26:30
and it's like really, really hard.
26:33
And, you know, then we we have to kind of reach that's when we get to
26:36
a point of being like, okay, maybe medication is what we have to do instead
26:39
of all these other non pharmacological options.
26:43
And know, documentation is so important in that case.
26:45
If you're if you're and I always say,
26:47
who are we giving the medication and what are we giving the medication for?
26:51
You know, if the patient is not sleeping and the caregiver has to go to work
26:56
in the morning and the person is up at night and the caregiver
27:01
is completely exhausted in the morning,
27:03
you're not affecting one person,
27:04
you're affecting an entire family.
27:06
So being very aware of why you're prescribing ~ is important.
27:11
So again, it's
27:12
It's a team effort with the patient and the caregivers being center of the team.
27:17
~ and ~ and you know, I th I think that's where ~ you know meeting with the patient,
27:23
meeting with their families, working with them ~ is so important because you're
27:27
being respectful and trying to deal with the issue and not look for ~ you know,
27:32
a one stop solution. And you know,
27:35
I always tell them, I know it's difficult,
27:36
but we are here in this with you.
27:38
~ you know, if this if
27:40
This medication doesn't work? Not a problem.
27:42
We'll try other things and we'll work with you on that.
27:45
So you're never going to let them set them adrift.
27:48
You are always going to be there,
27:49
tethered to them, working with them,
27:51
no matter how difficult ~ the the situation.
27:54
You know, and ~ it also it also challenges you to provide the best possible care
27:58
when the cer situation is very difficult.
28:00
And I that's what I always say,
28:01
you know, where when when things are at their worst,
28:05
I'm at my best as a as a physician and as a as a psychiatrist.
28:08
You know, I
28:09
All my senses are honed into w how how can I be most helpful to the patients I know?
28:15
I think you know, again for going on to some of the pharmacological some
28:20
of the non pharmacological treatments we've talked and you're saying these
28:23
are again first line treatments,
28:24
things that we want to focus on first as as doctors and physicians,
28:28
as, you know, exercise and caregiver education.
28:34
There are some of the other ones that I think people may think of as more woo woo,
28:39
a little kind of holistic ish or a little out there kind of treatments,
28:44
but
28:44
are very evidence based, things like you're saying music therapy,
28:48
aromatherapy.
28:49
Yeah, absolutely.
28:50
Yeah. Tell us a little bit about those and I guess some of the benefit
28:53
of those I yeah.
28:54
Yeah, so you know, if you look at if you look at the network meta-analysis that have
28:59
been done, and there are many over the last ~ decade that are,
29:01
they all show benefit. You know,
29:03
they you can't choose one over the other.
29:05
The best part of of of those is that they all seem to work.
29:09
They all seem to have an immediate effect and a long lasting effect.
29:13
And there's the booster effect as well.
29:15
So if you teach keep teaching skills to the caregivers,
29:18
they will be better at it. So they will they'll adapt,
29:21
they'll, you know, adopt, they'll
29:23
Do the different things. So I think non-pharmacological management of the center.
29:27
Education is the ~ core value here.
29:30
You know, you're educating the caregiver,
29:32
you're educating the patient. And then a better ~ educated caregiver
29:37
is a much better caregiver. So you can't pick one over the other.
29:40
Whatever is available, you're trying to implement.
29:43
Even a simple thing as redirection,
29:45
you know, simple thing as education.
29:47
More, hey, neurocognitive disorders.
29:50
Behavioral symptoms are inbuilt into that.
29:52
So don't take it as if it's a something separate.
29:54
It's part of the illness. That simple thing will be like,
29:58
this is why the illnesses. So it's not my my mother or father or spouse being nasty.
30:03
It's the illness that's making them the behave this way.
30:06
So a simple thing as that acceptance is a very important thing.
30:09
Redirection. Then if you have ability for music therapy,
30:12
reminiscence therapy. You know,
30:14
there's so many different things.
30:15
Pet therapy, you know, they're they're all ~
30:19
Beneficial, and the best part is no side effects.
30:22
You know, people don't fall because of music therapy,
30:26
you know, unless of course they're dancing vigorously or something of that sort.
30:29
But there is no clear ~ adverse effects ~ from these,
30:34
and you can build on these skills.
30:36
So there is there is that layering of knowledge and skill that happens with.
30:41
I remember seeing like a Netflix documentary,
30:44
one of those explained about music therapy.
30:46
And again, one of the main uses was with geriatric population,
30:52
how and then getting up and dancing a little bit as as much as they're able
30:55
to and how again, yes, there is evidence which shows that it can
30:58
be helps with behavior,
31:01
cognition, physical health as well.
31:04
So it's definitely something I remember.
31:07
I just remember seeing this like many,
31:08
many years ago. So this is like
31:10
Definitely has been out there for a while and I think again people just don't
31:14
utilize it as much, right? We don't keep it in our toolbox.
31:17
And you know, that it's also helps the caregiver,
31:19
right? It's something ~ as a as a team that the caregiver and the patient can do.
31:24
You know, ~ going dancing,
31:27
that's great. Exercise, ~ you know,
31:30
water, you know, hydrotherapy.
31:32
These are all these are all effective things and how how do they work?
31:36
I think it works by integrating the sensory activity together and
31:40
the neurons fire more, there's more social ~ connections,
31:44
and I think that's how it works.
31:45
And that may be oversimplifying it,
31:47
but that's how I think ~ you know,
31:49
I explained it to the patients and the family members how these kind of things work.
31:53
I mean, for example, reminiscence therapy,
31:55
going through, you know, photographs,
31:57
going through videos, these are all things remembering the good times.
32:01
You know, they evoke positive memory,
32:03
they they evoke a sense of cohesion,
32:06
like in a sense of family, a sense of belonging,
32:08
which is good for the patient.
32:10
You know, ~ these individuals
32:13
Have a lot of stress, especially when you're aging,
32:15
because you're losing your independence and you're depending upon other people
32:19
to be taking care of you. I would be terrified.
32:21
You know, that's the my biggest fear is I'm a very independent kind of person.
32:25
If I have to depend on other people for my daily life,
32:28
that's a very scary thought for me.
32:29
And every time I see an older person who's demented,
32:32
that's the first thought that comes.
32:33
How can I be a non-threatening presence and help them maximize their function?
32:39
So that's why healing is part of the
32:43
the important thing. So I'm not I'm not pro I'm not providing,
32:45
I'm healing. ~ a lot of the things that people are afraid or ~ you know.
32:51
Let's talk about medication a little bit then.
32:53
So Brex Pepperzole, one of again,
32:56
the newer ish kind of antipsychotics out there.
32:59
That seems like it's maybe the new king of what we should be using.
33:05
I wouldn't say I I definitely wouldn't say that.
33:06
You know, so but so there are you know before ~ Bec Propersol came and
33:12
you know the company did a great job.
33:13
They have four randomized control trials,
33:15
very similar to each other. ~ and they were very specific in what they were looking
33:19
at is for agitation in Alzheimer's disease dementia.
33:22
So agitation is not the only behavioral symptom.
33:24
So apathy is, depression is, anxiety is,
33:28
psychosis is. So for specific indication,
33:32
both breakproposol.
33:33
And Avility, which is the Dextromethylphan ~ bipropion combination,
33:38
have been have been FDA approved for that because they have shown shown benefit
33:42
and there are short term trials,
33:44
you know, there are 12 week trials,
33:46
~ you know, so they're short term.
33:49
The downside to it, it's not going to work for everybody.
33:52
So, you know, for agitation, it'll work for Alzheimer's disease as ~ dementia,
33:58
agitation it'll work. But what about frontotemporal dementia?
34:01
You know, what about vascular dementia?
34:03
Or what about dementia with lower body?
34:06
So it's not going work. So I think the physician should know that
34:09
non-pharmacological management remains the center.
34:12
But for specific indications, these two medications are highly beneficial
34:17
in those individuals. But they're the short-term solutions.
34:20
They're not, you know, you can't prescribe them for two years.
34:22
There is no data. And if you have emergent agitation,
34:25
that these are psychiatric emergencies,
34:27
you know, they are not they're not approved for PRN use.
34:31
You know, they're not approved,
34:32
they don't have an intramuscular or intraminous preparation.
34:35
So you may have to go to the other medications like I amzepine if
34:40
the patient is agitated, or I am haloperidol.
34:43
And those you would do in the emergency room or they are the inpatient psychiatric.
34:47
So for emergent agitation, I wouldn't recommend these medications.
34:50
But for non-emergent agitation,
34:52
~ in Alzheimer's disease dementia,
34:54
yes, definitely. There they are one of the two choices.
34:58
But there are other medications that are also beneficial because.
35:01
antidepressives, you the cytalopram ~ trials were positive.
35:04
~ there is the Cochrane review that looked at ~ you know,
35:08
~ cytalopram and surtraline being beneficial for agitation.
35:13
~ they're beneficial even for psychotic symptoms because although
35:16
the psychosis phenotypically, that means in terms of appearance looks very similar
35:21
to psychosis and schizophrenia,
35:22
but the neurobiology is different.
35:24
You know, there is there may be more polymorphisms of
35:27
the serotoninergic receptors or
35:30
There may be ~ you know cholinergic deficits leading into that.
35:35
So newer medications will come.
35:37
and I think people are trying to use ~ you know some of the other medications,
35:42
like Cobenphi is a great example.
35:43
You know, there are I think four ongoing trials of Cobenphi
35:46
for agitation and possibly psychosis.
35:49
~ you know, we're waiting for those results.
35:52
so again, newer medications or repurposed medications are coming into place.
35:57
So again, one size does not.
36:00
Yeah. And the other treatments are things like the cannabinoids
36:05
and how they're starting to get a little bit more discussed in dementia care,
36:09
like what
36:11
Yeah. ~ drenabinol is the one that has been tried more often.
36:14
It's the synthetic cannabinoid.
36:15
~ and there's data that it is beneficial in decreasing agitation,
36:19
you know, and it's very well tolerated.
36:21
There is a recent ~ trial that showed positive benefit,
36:25
and meta-analysis have shown that there are two meta-analyses that I have sort
36:29
of noted in the in the article,
36:32
which have been positive. So again,
36:33
early stages, but the issue is ~ acceptability.
36:37
I mean, every time you use
36:39
Cannabinoids, ~ everybody's looking,
36:41
my god, is my grandmother smoking pot?
36:43
No, you're not talking about street drug,
36:45
you're talking about medicinal value.
36:48
It's it's it's an FDA-approved medication.
36:50
~ and so acceptance becomes an issue.
36:53
So it's lowered down the algorithm of where we use it,
36:56
but then if you've tried all the other medications that's not beneficial,
37:00
absolutely worth a try. and I think it's 2.5 to 10 milligrams,
37:06
is I think the dosing that you can do for these individuals.
37:09
So I I know I have tried it with ~ benefits in certain cases.
37:12
So again, one size does not fit out.
37:15
Yeah. Always I think that's important to remember is like look at
37:18
the patient in front of you and the system around them and make your make your
37:22
choice from there.
37:23
Correct. Treat the patient, ~ no not the not the not the symptom.
37:27
Yeah.
37:28
Yeah. And the other kind of interventional ~ treatment that a lot of people
37:35
I think forget or overlook is ECT.
37:38
~
37:39
~ or any kind of interventional treatment like ECT,
37:42
TMS, ~ direct stimulation, all of them are are starting to emerge
37:47
as good treatments. Again, availability,
37:50
acceptability, and adaptability.
37:52
Three A's that I always talk about.
37:54
You know, ECTA, as you know, is the most effective treatment for many conditions,
37:59
including refractory depression,
38:01
diffractal schizophrenia, bipolar disorder.
38:03
But we don't use it because it becomes a political debate.
38:05
You know, people make a big deal about it,
38:08
but the evidence
38:09
You know, I trained in England before coming to the to the US.
38:12
We used to use ECT all the time.
38:14
Very safe and effective treatment.
38:15
Modern machines are very safe.
38:17
You know, we use the ~ you know the right unilateral ultra ~ brief pulse ECT.
38:23
Very safe ~ in ~ in these individuals and very effective.
38:28
And you're not doing it forever.
38:29
You know, you're doing a short course to help with the agitation,
38:32
beneficial. TMS emerging data that is actually not only helps with behaviors,
38:36
it also may help with cognition.
38:38
And various different versions of the TMS are going to come out,
38:42
which may show ~ benefits in the long run.
38:45
Again, it's the adaptability, acceptability,
38:48
and availability. So that you have to do that.
38:50
~ If it is available, you know,
38:52
would it would I consider that as first line treatment?
38:55
Probably not. You know, we have developed an algorithm where you use
38:59
~ you know colonesterase inhibitors,
39:01
nemantine as a first line. Then if the patient is still agitated,
39:05
we may use a you know abulity.
39:08
we may use breathcriposole, we may use respiridone,
39:10
we may use ~ you know adocrypazole,
39:13
~ we may use pallanzepine, cottapine.
39:15
If those don't work, then of course cannabinoids,
39:19
ECT, TMS are all all in the game at that stage stage of the treatment.
39:26
The other part of again, dementia care is again the caregivers.
39:31
We've been talking about the caregivers,
39:32
right? We've been talking about them as like all part of the team.
39:35
How much should we be looking at the caregivers themselves as well to be like,
39:41
hey, let's get you some care and the burden that this is on you and
39:47
how much is is bringing out of you?
39:49
I know I talk about a lot with my adult patients,
39:52
like caregiver fatigue and the burnout that occurs with that and
39:55
How much does it just wears on everybody?
39:58
So what can we do to help support the caregivers as well?
40:01
Yeah, so remember this is this is a team effort.
40:04
It really does take a village to take care of an older adult with
40:07
a psychiatric illness, whether it's neurocognitive disorder,
40:10
depression, ~ bipolar disorder,
40:12
schizophrenia. So I think that understanding is very important when you're seeing
40:16
these patients. So a rushed assessment where you're just not paying attention
40:21
to the nonverbal cues, what's right in front of you,
40:24
I think is a mistake. I think rather than just gathering information
40:28
And making a diagnosis and then giving some medication is not going to help
40:32
in the long run. So pay attention to the patient,
40:36
pay attention to the caregiver.
40:37
Always ask how the caregiver is doing dealing with the situation.
40:41
~ and you know, caregivers often are exhaustive,
40:45
caregivers are often upset because they've gone to other providers
40:49
who have not given them the time of day and probably make made them feel bad.
40:53
So I always, you know, I'm I'm doing it in the healing part,
40:56
I'm just listening.
40:57
~ because you know, within ten minutes of the patient and the family providing,
41:02
I know what I'm going to do. So I'm just confirming or ~ eliminating ~ the doubts.
41:07
So I spend a lot of time talking to the caregivers on simple techniques
41:11
and taking care of them. And if they need to see somebody,
41:14
you know, we always provide them with the resources for them.
41:17
And then of course Alzheimer's Association,
41:19
areas agents, area agencies on aging are all there to help.
41:22
so it's a team effort, not an individual effort.
41:25
But paying attention to both the patient and the caregiver is important.
41:29
If the caregiver is not going to be well,
41:30
the patient is never going to do well.
41:33
So you have to you have to remember that.
41:35
~ so and and I always like I said earlier,
41:38
patience is a virtue, you know.
41:40
~ just being able to sit and take it in and say,
41:43
Okay, how can I be most helpful to ~ to you?
41:46
Yeah. We're talking, I mean, about also guidelines
41:52
and ideal ways to treat, right?
41:55
And, you know, this is unfortunately this the word ideal comes in there,
41:59
right? 'Cause we know reality is not always plays nicely and kind
42:02
of like we mentioned before, just limitations,
42:05
whether it's manpower, finances,
42:07
whatever else it may be, like
42:11
How do we avoid getting into situations where we're like,
42:13
here's the guidelines, here's recommendations,
42:15
and then nobody can put them into place?
42:17
How how do we support that?
42:19
You know, ~ see guidelines are for me like a map.
42:23
You know, they they tell you here is the basic ingredients or basic way
42:27
of how you can proceed. Then you need to you need to figure it out and
42:31
you have to treat the individual in front of you.
42:33
So I use the guidelines as my roadmap,
42:37
~ but with the reality situation.
42:39
You know, ~ i it's like you know,
42:42
d driving on a rainy day is different from driving on a snow day,
42:45
is different from driving in bright sunlight,
42:47
right? So
42:48
You have to use the it may be the same map,
42:50
but it doesn't tell you the ground reality.
42:52
So I use the ground realities to see what is in up front.
42:56
I I am more cautious than ever before,
42:59
you know, ~ over the last 25 years as ~ attending geriatric psychiatrists.
43:03
I have become more and more cautious with giving medications.
43:06
So I give only when I'm absolutely happy to medication.
43:10
So and I am I'm a minimalist. I try to not give too many different things
43:14
and combination treatments only if monotherapy.
43:17
Trials have really been unhelpful.
43:19
So a lot of gathering information before the patient comes is also done,
43:24
a chart review and talking to other providers.
43:26
and then giving medications, along with little tips on how
43:31
to the non-pharmacal management is is what I do.
43:34
And frequent follow-up, you know,
43:36
once every ~ six to eight weeks possible in the nursing homes,
43:40
~ much more than that because people are more demented,
43:43
more agitated and have more.
43:45
morb polymorbidity in those situations.
43:47
So again you adapt to the basic ~ you know ~ ground realities but always stick
43:53
to the rules you know I'm not gonna do polypharmacy I'm gonna always
43:57
use non pharmacological management first.
43:59
If I can add pharmacological grade I'm gonna monitor,
44:02
start low, go slow. I think these are just you know things that it's like
44:05
a checklist. You know, you go through those,
44:07
I'm not gonna do this, I'm gonna do this,
44:09
I'm not gonna do this, do that.
44:10
Which will prevent you from ~ overreaching and causing harm.
44:17
like realizing as we talk more and there's like there's there's
44:20
a lot of similarities actually between like geriatric psychiatry
44:23
and channel addison psychiatry especially especially when I'm working with
44:27
a lot of like the developmental disability patients and the families that
44:30
are out there. And something else kind of like came to me,
44:34
it was I I also agree with you that I try to do everything else first.
44:39
And medication is like a last resort.
44:42
And you know, we don't want to use out bring out the the quote unquote
44:45
big gun medications, you know,
44:46
from
44:47
I got a mind the other bilifies,
44:48
whispered all the antipsychotics,
44:50
et cetera. You know, again, because of concerns about black spot warnings
44:54
and then some of the effects, meta cardiac effects that it has.
44:58
But then I I run into situ situations where we wait,
45:04
we wait, we wait, we wait, we delay prescribing,
45:07
and then eventually at some point in time we prescribe it,
45:10
or almost feel like we're forced into prescribing something,
45:13
and then parents are like,
45:16
this made such a huge difference.
45:18
We should have done this six months ago,
45:20
a year ago. Why did why do we delay?
45:25
So, Dr. Bridge, it's not as simple as that,
45:27
right? So the ground realities are the ground realities.
45:30
If you think that, so for example,
45:31
a patient comes and you're seeing them in the emergency room.
45:35
You know, the patient is swinging the chair,
45:37
you know, using the butter knife to try to snap,
45:40
that's an emergent situation. You have to use your medications.
45:42
You start, you treat, you monitor,
45:45
and you taper off and discontinue.
45:47
So that's an emergent situation.
45:48
Also, when people say, we should have used it then,
45:52
but you you are monitoring the situation.
45:54
So
45:55
It may not have been feasible at that time to use the medication.
45:58
You have really go through that.
45:59
That's why I always say treat the treat the patient,
46:02
not the symptom. You know, each stage is different and you're getting more
46:05
and more information. And if you find a if you find a great medication,
46:09
that's that's that's wonderful.
46:10
~ and you know it's chronic disease management is very different.
46:14
~ I always say it's different for us who the manage chronic diseases than from
46:20
an orthopaedic surgeon who's curious curing ~ or doing surgery for a broken bone.
46:24
You know, that's very different.
46:25
So let me give you an example.
46:27
So if you tell a patient with diabetes,
46:30
hey, go take this GLP one and your diabetes is great,
46:33
it doesn't do squat. You know,
46:36
it's there is a whole social prescribing that needs to happen.
46:39
Hey, you need to take care of your eyes,
46:41
you need to take care of your heart,
46:42
you need to take care of your kidney,
46:44
you need to take care of your toes,
46:46
you need to eat healthy, you need to stop smoking,
46:49
you need to decrease your alcohol,
46:50
you need to lose weight. That's the point.
46:55
A medication is only gonna as good as the plan which is put in.
46:58
Right? it's like putting a great engine on a on on a car which has bad transmission.
47:05
It's not gonna run. You know? So I I think I think we I think we miss
47:10
I think in this ~ looking at the parts,
47:12
we miss the whole picture. So I always tell my residents,
47:15
focus on what's right in front of you.
47:17
Because there's a lot of things that are unsaid and you need to know.
47:21
~ caregivers may
47:24
you know, may not tell you all the stuff.
47:25
So asking them how can I be most helpful?
47:28
And just be willing to listen and then adapt to the realities of what what
47:34
is in front of you. Sometimes you may need to medic use medication.
47:36
There are times where I have had to use medication,
47:39
right? As I you know, I'm like,
47:40
hey, this needs to be treated now because safety becomes an issue.
47:44
So I I think just adapting and listen listening and adapting,
47:47
I think is the way I would
47:49
Yeah. Last kind of c question.
47:52
Yeah. Dementia care again,
47:56
like a of people focus that again on the memory loss and let's slow memory loss,
48:01
less slow memory loss. And again,
48:02
with with what we're talking about more,
48:04
we're looking at quality of life,
48:05
preserving quality of life as much as possible.
48:07
But how do you define success when you're treating these behavioral symptoms
48:13
of dementia? What does that look like for you?
48:15
That's that's a great question.
48:16
~ so again, success each in each patient is very different.
48:20
So I talk to the patient, the caregiver,
48:24
and then we come up with what we would rate as being successful.
48:27
So is it reduction of symptoms?
48:30
Is it ~ you know, decrease in the caregiver's stress,
48:35
or is it improved functionality,
48:38
or is it all of those things together?
48:40
So again, we would put and success is different at different stages as well.
48:44
You know, once you're severely demented,
48:47
just not hitting the caregiver may be considered a major success.
48:51
Whereas if you're mildly demented,
48:53
you know, being functional, attending activities for the family,
48:58
~ decreasing ~ irritable outbursts,
49:01
maybe all of those. So again, depending upon the stage of the illness
49:04
and what ~ what the care patient and the caregiver wants,
49:07
you you adapt success based on that.
49:10
but I would never have it.
49:12
my my success. You know, I consider every treatment,
49:15
whether they're successful or not,
49:17
as a as a successful intervention.
49:19
As long as I am able to understand,
49:22
appreciate, and provide support and provide healing to the patients and families,
49:28
I find this is as very successful.
49:30
Even even the worst outcomes, sometimes I'm like,
49:32
you know, I tried my best. You know,
49:34
I have I did everything that I can.
49:36
That's that's why having a checklist,
49:38
having a guideline or protocol,
49:41
And having constant feedback, you know,
49:43
of you know what you did right and what you did wrong.
49:46
so with our residents, every every afternoon from four to five o'clock after clinic,
49:52
we do, we do a deep debt. You need to really know how you did in the
49:57
the time you spend with the patient,
49:58
which is I think, which is I think one of the most powerful tools that we have.
50:02
because you have to learn from your mistakes as well.
50:06
Yeah. I think that's that's very important.
50:08
And think ~ well I I do my usual last question and I think you kind
50:12
of segued us naturally into there is as a healer,
50:16
right? As somebody who does the healing work and working with this population,
50:21
which is extremely, extremely challenging,
50:23
what is your self care? What is what is your self healing?
50:26
Yeah, no, I people ask me that all the time.
50:29
~ as I age, I ~ mortality becomes a very real thing for me.
50:33
~ s issues associated with aging becomes very real for me.
50:37
~ and I always say, you know, full life is what you decide it is going to be.
50:42
So I do a lot of things ~ that I you know I've always wanted to do.
50:46
So the bucket list I could keep doing.
50:48
Driving to work and driving from work and decompressing myself and playing
50:53
out what my day is going to be.
50:55
And then at the end of the day,
50:56
I'm going through what my day was and learn from that.
50:59
So I think I'm a better human being,
51:02
a better psychiatrist, a better geriatric psychiatrist from the day before.
51:06
it may not have been a perfect day,
51:08
but it was the day from which I learned.
51:10
Sometimes you have lots of not so great news,
51:14
but you know what? It's not gonna put me down.
51:16
So self-healing is what I have learned to do.
51:19
And I I do a lot of other things outside.
51:21
You know, I ride my motorcycle,
51:22
you know, I I
51:24
watch whatever I like to watch.
51:25
I like podcasts. I like reading.
51:27
And I'm I'm constantly learning and evolving as a human being,
51:30
which I think makes me a better psychiatrist.
51:32
I'm well arounded, like I said before,
51:35
I I I'm very cautious with medications because I know all the good and
51:39
not not so good things that come out of medications.
51:42
So ~ it it just makes you I think more aware ~ and and you know
51:47
it brings humility to you because you may not be able to help everybody
51:50
but you're gonna definitely try.
51:53
Yeah. I think it's a great message.
51:54
I think it's important for us to like do all those things.
51:58
I know my voice is a little bit different today because I was out screaming
52:01
at a concert last night. So, like,
52:03
you know, like you said, getting those buck one of the bucket list groups
52:07
off my list. And I was like, you know,
52:08
I have have to do that. So that's very,
52:11
very important for for us as well.
52:12
So thank you, Dr. Tempe, so much for your time and your work that you do.
52:16
Yeah.
52:17
I can have my sir.
52:18
I think for the conversation and for everybody else,
52:21
you know, this is the
52:23
August special report podcast on psychiatric news.
52:27
You can find it in the August issue online and in print.
52:31
Remember to rate, review the podcast,
52:33
give us five stars. And we will see you next month for the next September special
52:40
report. Thank you so much.