Systematic appraisal of dementia guidelines for the management of behavioural and psychological symptoms

Background: Within the treatment of dementia, management of behavioural and psychological symptoms (BPSD) is a complex component.

Purpose: We wanted to offer a pragmatic synthesis of existing specific practice recommendations for managing BPSD, based on agreement among systematically appraised dementia guidelines.

Data sources: We conducted a systematic search in MEDLINE and guideline organisation databases, supplemented by a hand search of web sites.

Study selection: Fifteen retrieved guidelines were eligible for quality appraisal by the Appraisal of Guidelines Research and Evaluation instrument (AGREE), performed by 2 independent reviewers.

Data extraction: From the 5 included guidelines, 18 specific practice recommendations for BPSD were extracted and compared for their level of evidence and strength.

Data synthesis: No agreement was found among dementia guidelines for the majority of specific practice recommendations with regard to non-pharmacological interventions, although these were recommended as first-line treatment. Pharmacological specific practice recommendations were proposed as second-line treatment, with agreement for the use of a selection of antipsychotics based on strong supporting evidence, but with guidance for timely discontinuation.

Limitations: The appraisal of the level of agreement between guidelines for each specific practice recommendation was complicated by variation in grading systems, and was performed with criteria developed a posteriori.

Conclusion: Despite the limited number of recommendations for which agreement was found, guidelines did agree on careful antipsychotic use for BPSD. Adverse events might outweigh the supporting evidence of efficacy, weakening the recommendation. More pivotal trials on the effectiveness of non-pharmacological interventions, as well as guidelines specifically focusing on BPSD, are needed.