Management of the Behavioral and Psychological Symptoms of Dementia (BPSD)

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As their dementia progresses, most patients will develop BPSD.  These symptoms may be short-lived, intermittent or persistent.  Psychotic symptoms are the most disturbing for the patient and caregivers and include:

  • Hallucinations or delusions affect 20 percent of Alzheimer’s Dementia (AD) patients
    • Hallucinations are perceptions without stimuli and are most often visual
    • Delusions are fixed, idiosyncratic or false perceptions or beliefs with little if any basis in reality and are not the result of religious or cultural norms.  Delusions can be suspicious (paranoid) grandiose, somatic (medical illness that does not exist), self-blaming or hopeless
  • Psychotic symptoms are often related to the current mood:  i.e. in depression, delusions that one is poor or dead; in mania, grandiose delusions, elevated self-regard

Risk Factors for Psychotic Symptoms in Older Adults

  • Chronic bed rest
  • Cognitive impairment
  • Female gender
  • Sensory impairment
  • Social isolation

Other Common Neuropsychiatric Symptoms Associated with Dementia

  • Depressive Symptoms
    • Seen in up to 40 percent of Alzheimer’s patients, may precede disease onset
    • Signs include sadness, loss of interest in usual activities, anxiety and irritability
    • Suspect if patient stops eating or withdraws
  • Apathy
    • High prevalence and persistence throughout the course of AD
    • Causes more functional impairment than expected for cognitive decline
  • Manic-like Behavioral Symptoms
    • Signs include pressured (hurried) speech, disinhibition, elevated or irritable mood, intrusiveness, hyperactivity, impulsivity and reduced sleep
  • Agitation or Aggression
    • Seen in up to 80 percent of AD patients
    • A leading cause of nursing home admission
    • Always identify and examine context of behavior (harmful to self or others) and environmental triggers that may include overstimulation, unfamiliar surroundings or frustrating interactions
    • Determine whether delusions or hallucinations are interfering with function
    • Exclude physical discomfort, such as pain, hunger or infection

Management of Symptoms Associated with Dementia

  • Always attempt these interventions before considering medications
    • Scheduled toileting and prompted toileting for incontinence
    • Assistance with activities of daily living, role modeling, cueing, positive reinforcement to increase independence  or decrease dependence
    • Avoid confrontation, try redirection instead
    • Maintain a calm demeanor
    • Use services of caregiver support groups
    • Music during meals and bathing
    • Walking or light exercise
    • Simulate family presence with video or audio tapes
    • Pet therapy
    • Speak at patient’s comprehension level
    • Utilize bright light and white noise
    • For intermittent disruptive behaviors, identify and avoid antecedents/triggers of the behavior
  • Add drug therapy only if there is an immediate threat to self or others
    • Target drug treatment to specific symptoms (see below)
    • Start with low dose and increase only if effective and necessary
    • Reevaluate frequently for effectiveness and side effects of treatment
    • If side effects appear, consider dose reduction or drug discontinuation before adding another drug to treat side effects
    • If symptoms resolve, consider gradual dose reduction at least every 3-6 months with goal of drug discontinuation
    • If symptoms persist, consider alternative treatment and/or consult with specialist

Medications used to Manage the Neuropsychiatric Symptoms Associated with Dementia

  • Psychotic Symptoms (delusions, hallucinations)
    • Low dose, second-generation antipsychotic including risperidone, aripiprazole or quetiapine
  • Depressive Symptoms
    • Antidepressants, such as escitalopram, mirtazapine and bupropion
  • Apathy
    • Antidepressants like escitalopram, mirtazapine or bupropion
  • Manic-like Behavioral Symptoms
    • Mood stabilizers, which could include divalproex sodium, lamotrigine and carbamazepine


Source: A guide to the management of psychotic disorders and neuropsychiatric symptoms of dementia in older

Adults April 2011 American Geriatric Society