Psychological and behavioral symptoms of dementia
People are living for longer, and it is therefore increasingly likely to know someone affected by dementia. In Spain there are more than 700,000 cases and this number is expected to rise in the coming years, due to the aging of the population.
Cognitive impairment (dementia) is disabling for those affected by it, and is devastating for the family members and caregivers. It is one of the main causes of disability and dependence in the elderly.
It is easy to suspect dementia when there are memory lapses or disorientation, but it is more challenging when the main symptoms are only changes are in character or in behavior.
Behavioral and Psychological Symptoms of Dementia
The term Behavioral and Psychological Symptoms of Dementia (BPSD) is used to define the behavioral reactions and psychological symptoms that occur in people with cognitive impairment of any origin. They are frequent and may be due to the cognitive impairment itself, or they can be the consequence of intercurrent medical, psychological or environmental condition.
Behavioral symptoms can be identified through observation, while psychological symptoms are identified through interaction with the affected person. It is typically the caregiver or the family member who identifies the psychological symptoms.
Different Behavioral and Psychological Symptoms of Dementia are described below:
- Depression: Individuals appear sad and dull, and may express feelings of being a burden.
- Irritability: Individuals may be moody, impatient and intolerant. They may overreact or lose temper with trivial things.
- Fear: Individuals feel unconfident, apprehensive, or insecure
- Anxiety: Internal tension, which does not allow to be calm.
- Restlessness: Inability to stand still due to anxiety and internal tension.
- Nervousness: Restlessness as a consequence of anxiety and internal tension.
- Agitation: Individuals feel intensely restless and worried, and are unable to calm down. They may react aggressively.
Aggression
- Verbal: They may insult, threaten or raise their tone.
- Physical
- Against people: They may hit, push or spit on other people.
- Against objects: They may throw things, slam the door, hit furniture or other objects, etc.
- Oppositionism: They present aggressive resistance to basic activities such as grooming, eating or dressing.
- Apathy: Loss of interest and motivation. There is lack of excitement and enthusiasm.
- Changes in eating behavior:
- Loss of appetite: Loss of the drive to eat.
- Increased appetite: There is an increased desire for food.
- Hyperphagia: Eating more food than necessary. Binge eating. Individuals may put excessive food into their mouth, which can induce choking.
- Hyperorality: Individuals have hyperphagia and may want to eat unhealthy foods, limited food groups (typically carbohydrates), or even inedible material.
- Sleep changes: Different sleep changes may appear in people with dementia.
- Hypersomnia: There is excessive sleepiness.
- Insomnia: There is lack of sleep.
- Fragmented sleep: Sleep is interrupted and discontinuous due to awakenings.
- Loss of sleep-wake cycle: This is when the biological clock is not synchronized with the environment. In the extreme case in which there is a total inversion of the biological rhythm, the individuals are sleepy during the day and active at night.
- REM sleep behavioral disturbance: Affected individuals move, talk and live out their dreams, sometimes in a violent manner (kicking, punching or screaming). Unintentional harm to the bed partner or self harm can occur. REM sleep behavioral disturbance is usually suspected by a third party.
- Personality or character change: Individuals may lose their essence, and act in a way that is different to the old self. They can appear more fearful and insecure or, on the contrary, more impolite and ruder. Being more impatient, distrustful, rigid, insensitive, or apathetic than usual are other possible personality changes.
- Cognitive rigidity: Individuals become less and less mentally flexible and show little ability to adapt to circumstances or changes of routine. They want things to be done their way.
- Loss of empathy: Individuals lose interest in the feelings of others and may show superficial emotion.
- Loss of social cognition: Individuals lose the sense of social values and the ability to adapt to the social world. They may steal food from other people’s plate, or may use their fingers to eat. They may appropriate other people’s belonging.
- Impulsivity: Lack of foresight or social tact in language, body language or other behaviors.
Disinhibition
- Behavioral disinhibition:
- Repetitive compulsive behaviors.
- Sexual disinhibition behaviors: Increased sexual behavior with loss of modesty.
- Disinhibition of thoughts:
- Becoming more extroverted and impulsive.
- Making comments that are out of place or socially inappropriate.
- Using inappropriate language.
- Lack of judgment: Loss of the ability to make decisions. Individuals lose the capacity to take into account and to evaluate different factors that are necessary for decision making.
Delusions
Erroneous beliefs that are tenaciously hold without evidence to support them. Things are not perceived as they are.
- Persecutory delusion: Individuals are preoccupied that they are being conspired against, followed or harmed.
- Delusion of poisoning: Believing that they are being poisoned, typically through food or medication.
- Delusional misidentification:
- Typically believing that the identity of a loved one has been supplanted by an impostor. This type of misidentification is called Capgras syndrome.
- Not identifying their home as theirs, and thinking it is someone else's home.
- Jealousy delusion: Believing that the partner or lover is unfaithful.
- Delusion of theft: Individuals believe they are being robbed because they cannot locate their belongings.
Hallucinations
Perceptions that involve the senses, in the absence of external stimuli. They are felt like real, but cannot be confirmed by anyone else. They can cause positive or negative experiences. There are different types of hallucinations:
- Visual: Individuals perceive images of something that is not there. Misidentifying an object for a person or for an animal can be a mistake instead of a hallucination, typically in the context of low vision.
- Auditory: The person hears something that is not real. It can be a voice, a sound, a melody...
- Olfactory: The person perceives a smell that cannot be confirmed by anyone else.
- Tactile: Individuals experience tactile sensations through the body without anything touching them. They may feel bugs crawling around them or feel pressure on their skin or organs.
- Childish attitude: Seemingly childish behaviors: tantrums, outbursts, opposition, irrationality, manipulation.
- Follower behaviors of the caregiver: Following the caregiver like a shadow. Search for constant attention, security and comfort.
- Wandering: Individuals roam around and can potentially get lost. In people with physical or balance limitations, there is also a risk of fall.
- Repeated and stereotyped actions
- Vocalizations: utterances that are typically repetitive and loud. They can consist of sounds, words or small phrases.
- Repeated actions such as repeatedly taking off the belt or moving things around.
It is important to acknowledge that dementia is not only memory loss and disorientation. There are in fact many other symptoms that are very frequent and can be even more disabling than amnesia itself.
Recognizing the Behavioral and Psychological Symptoms of Dementia is key to early identification of cognitive impairment and to prompt intervention. It is also essential to guide and support family members and caregivers in the management of the affected persons.
About the author
María Isabel Zamora is a physician with a double specialty in Psychiatry and Neurology. She has experience in the care of patients in general psychiatry consultations, and in a more specialized way, in the care of patients who combine psychiatric and neurological symptoms. She has worked with psychogeriatric patients and patients with functional diversity. She has experience in cognitive impairment, psychological and behavioral symptoms of dementia, psychiatric symptoms related to neurological disorders or chronic pain, autism, ADHD, adaptive disorders, depression, anxiety, addictions, bipolar disorder, obsessive-compulsive disorder, sleep disorders, eating disorders, etc.
Division of Medicine
Psychiatrist
Adults and adolescents
Languages: English, French and Spanish
Tension-type headaches: Stress or neurological problem?
Tension-type headaches are common and can significantly decrease one’s quality of life. Although it is a neurological condition, it has been related to stress, anxiety, and depression. In the last decades, an increase in frequency has been observed. It is therefore useful to learn more about them in order to treat them early and prevent them.
This article will help you recognise the typical features and learn about the possible causes, the treatment options and the way to prevent them through stress management.
What is a tension-type headache?
It is the most common type of headache amongst people. It has been related to stress and anxiety, although its exact mechanism is still yet to be understood. Other name: Stress headache.
How does a tension-type headache hurt? The pain feels like a pressure on both sides of the head, as if an elastic band were squeezing the entire head. Unlike a migraine, the pain is not so much throbbing, but rather continuous and persistent. The intensity may be mild to moderate, and the duration is variable, lasting from hours to days.
Depending on their frequency and duration, they are divided into two subtypes. Episodic headaches, which occur for less than 15 days in a month, and chronic headaches, which are present for more than 15 days in a month.
Causes of tension-type headaches:
- They have been related to anxiety, stress, and depression, but psychological disorders are not the only possible explanation, as they have also been related to local problems and genetic factors.
- It is therefore reasonable to wonder if they are of neurological nature or, instead, if they are due to psychological origin.
- The reasonable answer would be that, behind the neurological mechanisms implicated, there is most certainly a strong influence of the underlying psychological factors.
- In tension-type headaches, the muscles surrounding the skull are characteristically tense, and this is typically due to internal psychological tension. As the muscles are constantly activated, they end up becoming more sensitive to stimuli and, by this, previously innocuous stimuli can become painful.
- Other times, muscle tension is due to visual fatigue or to local issues such as neck pain or temporomandibular joint disorders. In these cases, something similar occurs. From the sustained tension due to overexertion or discomfort, the pain receptors of the muscles end up being sensitized, resulting in an increased perception of pain.
- On the other hand, there are also pain processing centers in the brain that are implicated in pain regulation. It is suspected that affective disorders can alter the functioning of these control centers and, thereby, pain sensitivity may also increase.
Some of the triggers of tension-type headaches: Fatigue, hunger, poor sleep, neck pain, bruxism (teeth grinding), maintained inadequate postures, insufficient hydration, toxic substances such as tobacco, alcohol, or caffeine.
How is tension-type headache diagnosed?
Physicians are generally able to diagnose tension-type headache through medical history. Physical and neurological examination helps them rule out other conditions, and brain imagery such as Computed Tomography or MRI can help clarify uncertain cases. Doctors ask over features, location, duration, intensity and frequency of pain. They also ask for symptoms of other conditions such as vision problems, language, sensitivity, and mobility disturbances, which are not typical of tension-type headache.
When to consult a doctor?
Call 112 in case of headache of sudden and severe onset. Also, if it comes with weakness or numbness of the face, arm, or leg, or if there is difficulty in walking, seeing, speaking or understanding.
It is recommended to schedule an appointment when headaches are not relieved with usual medication, when they interfere with daily life, or when there are changes in the features. In most cases, General Practitioners are familiar with tension-type headaches, although the specialists are the Neurologists. When major affective disorders are suspected at the origin, an assessment by a psychiatrist or a psychologist is advised, to treat them. At Sinews, we can help you with specialized care aimed at solving the underlying emotional disorder.
Treatment of acute episodes of tension headache:
Over-the-counter medications are available to treat acute episodes. For episodic headache, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, aspirin or naproxen are indicated. For those who do not tolerate NSAIDs or who have allergies, paracetamol is recommended. It is very important to limit the use of analgesics to prevent the headache from becoming chronic and transforming into analgesia abuse headache, which appears when these drugs are taken regularly. Patients suffering from chronic tension headache (for more than 15 days per month) should consult a physician for preventive treatment. Amitriptyline is usually recommended for those cases.
When a tension headache occurs, in addition to analgesics, other non-pharmacological measures can help to manage the pain. In an acute episode, irritants (such as coffee, nicotine, alcohol or other intoxicants) should be avoided and environmental irritants (noise) should be minimized. Home remedies: Isolate yourself in a quiet room. Lying in bed. Close your eyes and focuse on your breathing, which should be slow and deep. Apply light pressure on the temples with the tips of the fingers. In case of muscular tension in the neck or shoulders, a physiotherapist can help to treat the contractures and soreness. If this is not possible, gentle heat can be applied to the most tense area with a seed bag or simply with water from the shower. Also, one can gently massage the painful area of the shoulders and back of the neck, by gently pressing with the fingers in circles.
Prevention of tension headache
To improve the quality of life, the most important thing is to prevent headaches so that they become less frequent and limiting. Tips to prevent tension headaches:
- Maintain proper posture when working, writing or reading.
- Hydrate sufficiently.
- Perform neck exercises and stretching when holding fixed postures for long hours.
- Ventilate the room.
- If you need glasses, wear them. If you spend a lot of time in front of a screen, do exercises to rest your eyes by looking away from the screen for a few seconds.
Reduce tension headache by managing stress. To prevent headaches from becoming prolonged or chronic, it is essential to address the stress and anxiety that facilitate them.
Managing stress to reduce tension headaches
It is difficult to avoid and completely isolate yourself from the stressors of daily life, but what you can do is learn to manage stress. This will reduce the impact of stress on mental and physical health and improve headaches. These are 15 recommendations to reduce stress:
- Make physical exercise a habit. Consult your doctor to find out what exercise is best suited to your health.
- Go for walks and outdoor activities.
- Eat a healthy and balanced diet, including fresh foods.
- Adopt healthy lifestyle habits avoiding caffeine, alcohol and other toxins.
- Sleep enough hours at night and avoid oversleeping.
- Avoid overexposure to electronic devices and social networks.
- Organize your time.
- Simplify your life. Make realistic plans and avoid overloading yourself.
- Recognize your achievements and reduce self-demand.
- Allow yourself to rest throughout the day.
- Set your limits.
- Ask for help and learn to delegate.
- Change your routine. Sometimes a change in routine is necessary.
- Change your perspective. Consider that the glass may be half full. Adopt a positive attitude.
- Don't lose your sense of humor. Laughing relieves tension.
Tension headache is very common and can limit the quality of life of those who suffer from it. Although the causes are not fully understood, neurological sensitization to pain may in part be explained by underlying anxiety, depression and stress. There are different ways to treat acute episodes, although if the response is not as expected, it may be necessary to consult a physician. It is important to treat underlying emotional problems to prevent tension headaches. An assessment by psychiatry or psychology may be necessary if you are unable to manage your anxiety or depression on your own. At Sinews we can offer you targeted psychological or psychiatric treatment to help you overcome your discomfort.
About the author
María Isabel Zamora is a physician with a double specialty in Psychiatry and Neurology. She has experience in the care of patients in general psychiatry consultations, and in a more specialized way, in the care of patients who combine psychiatric and neurological symptoms. She has worked with psychogeriatric patients and patients with functional diversity. She has experience in cognitive impairment, psychological and behavioral symptoms of dementia, psychiatric symptoms related to neurological disorders or chronic pain, autism, ADHD, adaptive disorders, depression, anxiety, addictions, bipolar disorder, obsessive-compulsive disorder, sleep disorders, eating disorders, etc.
Division of Medicine
Psychiatrist
Adults and adolescents
Languages: English, French and Spanish