# Behavioral and Psychological Symptoms of Dementia

## Introduction

**Behavioral and psychological symptoms of dementia (BPSD)** affect up to 90% of individuals with dementia over the course of illness. These symptoms include agitation, aggression, psychosis, depression, apathy, disinhibition, and sleep disturbances. BPSD cause significant distress to patients and caregivers, drive institutionalization, and increase mortality. Management requires a systematic, non-pharmacological-first approach.

## Classification of BPSD

### Behavioral Symptoms

**Agitation and aggression**: physical (hitting, pushing) and verbal (screaming, cursing) **Wandering** and exit-seeking behavior. **Disinhibition**: inappropriate sexual behavior, undressing, rude comments. **Repetitive behaviors**: repeated questions, pacing, hoarding. **Resistance to care**: refusal to bathe, dress, or take medications.

### Psychological Symptoms

**Psychosis**: delusions (theft, infidelity, abandonment) and hallucinations (visual more than auditory) **Depression and dysphoria**. **Anxiety**. **Apathy**: the most common and persistent BPSD, often mistaken for depression. **Sleep disturbances**: sundowning, day-night reversal, fragmented sleep.

![Categories and prevalence of behavioral and psychological symptoms of dementia](images/bpsd-categories-prevalence.png)

## Etiology and Contributing Factors

### The Unmet Needs Model

BPSD often reflect **unmet physical, emotional, or environmental needs** that the patient can no longer communicate. Pain, constipation, urinary retention, hunger, thirst, and boredom are common triggers. **Pain is underrecognized** in dementia patients; a trial of scheduled analgesics should be considered.

### The ABC Model

**A**ntecedent: what triggered the behavior? **B**ehavior: what exactly did the patient do? **C**onsequence: what happened immediately after? Systematic ABC charting helps identify patterns and modifiable triggers.

### Medical Causes to Rule Out

Delirium superimposed on dementia (the most critical differential) Urinary tract infection, pneumonia, constipation. Medication side effects (anticholinergics, benzodiazepines, opioids) Uncontrolled pain. Sensory deficits (uncorrected vision or hearing loss)

## Non-Pharmacological Management

### First-Line Approach

Non-pharmacological interventions should **always be attempted before medication**. Evidence supports multiple approaches; effectiveness varies by symptom and individual.

### Specific Interventions

**Music therapy**: reduces agitation and improves mood; personalized playlists are most effective. **Reminiscence therapy**: uses photographs, music, and objects to engage long-term memory. **Structured activities**: tailored to the individual's prior interests and remaining abilities. **Environmental modifications**: adequate lighting, reduced noise, clear signage, safe wandering paths. **Caregiver education and support**: training in communication techniques and behavioral management. **Validation therapy**: acknowledging and empathizing with the patient's emotional experience rather than correcting factual errors. **Aromatherapy**: lavender and lemon balm have modest evidence for reducing agitation.

### Person-Centered Care

Understand the patient's biography, preferences, routines, and values. Maintain consistency in caregivers and daily schedules. Use calm, simple communication with appropriate tone and body language. Avoid confrontation, restraints, and forced activities.

![Non-pharmacological intervention ladder for BPSD management](images/bpsd-nonpharmacological-ladder.png)

## Pharmacological Management

### General Principles

Use medication only when non-pharmacological interventions are insufficient and the patient or others are at risk. Target specific symptoms rather than treating globally. **Start at the lowest effective dose** and reassess within 4-6 weeks. Plan for deprescribing: attempt dose reduction or discontinuation every 3-6 months.

| BPSD Target Symptom | First-Line Pharmacotherapy | Dose Range (Elderly) | Key Evidence/Notes |
|--------------------|--------------------------|---------------------|-------------------|
| Agitation/Aggression | Risperidone | 0.25-1 mg/day | Best evidence; FDA black box warning for mortality |
| Agitation (alternative) | Citalopram | 10-20 mg/day | CitAD trial; QTc concern >20 mg |
| Agitation (newer) | Brexpiprazole | 0.5-2 mg/day | FDA-approved for Alzheimer's agitation (2023) |
| Psychosis | Risperidone or aripiprazole | Low dose | Avoid in Lewy body dementia |
| Depression | SSRIs (sertraline, escitalopram) | Standard geriatric doses | First-line for mood symptoms |
| Sleep disturbance | Trazodone | 25-50 mg HS | Low risk; no abuse potential |
| Apathy | Cholinesterase inhibitors | Standard doses | Modest effect; distinguish from depression |
| Moderate-severe NPS | Memantine | 5-20 mg/day | May reduce irritability; add to ChEI |

### Antipsychotics

**Risperidone** has the best evidence for aggression and psychosis in dementia; modest effect sizes. Aripiprazole and quetiapine are alternatives. FDA **black box warning**: increased risk of death in elderly patients with dementia-related psychosis (approximately 1.6-1.7x risk) Risk of cerebrovascular events, metabolic syndrome, falls, sedation, and parkinsonism. Avoid in **Lewy body dementia** due to severe neuroleptic sensitivity.

### Antidepressants

**Citalopram** (up to 20 mg in elderly due to QTc prolongation risk) has evidence for agitation (CitAD trial) SSRIs are first-line for depression and anxiety in dementia. **Trazodone** in low doses (25-50 mg) may help with agitation and sleep.

### Other Agents

**Cholinesterase inhibitors** (donepezil, rivastigmine, galantamine): modest benefit for apathy and neuropsychiatric symptoms. **Memantine**: may reduce agitation and irritability in moderate to severe dementia. **Carbamazepine**: limited evidence for aggression; requires monitoring. **Dextromethorphan/quinidine (Nuedexta)**: FDA-approved for pseudobulbar affect, studied for agitation in Alzheimer's disease. **Brexpiprazole**: FDA-approved for agitation associated with Alzheimer's dementia.

### Medications to Avoid

**Benzodiazepines**: increase fall risk, paradoxical disinhibition, delirium; avoid except for acute crisis. **Anticholinergics**: worsen cognition. **Typical antipsychotics**: higher EPS risk and mortality.

![Pharmacological decision algorithm for BPSD by target symptom](images/bpsd-pharmacological-algorithm.png)

## Key Clinical Pearls

Always look for delirium before attributing new behavioral changes to BPSD progression. Apathy and depression in dementia are distinct syndromes; apathy involves reduced motivation without sadness. Caregiver burnout is a medical emergency in its own right; always assess and support the caregiver. Antipsychotic use should be time-limited with documented informed consent discussions about mortality risk. A trial of scheduled acetaminophen (1 g three times daily) significantly reduced agitation in nursing home studies.

## References

1. Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. *BMJ*. 2015;350:h369.
2. Livingston G, Kelly L, Lewis-Holmes E, et al. Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials. *Br J Psychiatry*. 2014;205(6):436-442.
3. Schneider LS, Dagerman K, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. *JAMA*. 2005;294(15):1934-1943.
4. Porsteinsson AP, Drye LT, Pollock BG, et al. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. *JAMA*. 2014;311(7):682-691.