Behavioural and Psychological Symptoms of Dementia (BPSD)

Behavioural and Psychological Symptoms of Dementia (BPSD) will develop in more than 90% of individuals diagnosed with dementia.[1] Symptoms include delusions, hallucinations, aggression, screaming, restlessness, wandering, depression, and anxiety. Other symptoms include disinhibition, sexual behaviours, apathy, sleep disturbances, and compulsive or repetitive behaviours. BPSD results in impaired quality of life, increased cost of care, rapid cognitive decline, and massive caregiver burden.


BPSD is extremely common in the community (60%), and in nursing homes (80%). More than 90% of patients with dementia develop BPSD over 5 years, and the majority of cases have serious clinical implications.[2]

Is It Really Agitation?

Be careful when using the word “agitation” in a clinical context, as this is thrown around by various clinical staff without understanding the meaning behind it. Agitation is inappropriate verbal, vocal, or motor activity that is not judged by an outside observer to result directly from apparent needs or confusion of the agitated individual.[3] This means you must always need to understand if there were environment triggers or behaviours behind the “agitation.”

BPSD symptoms can be organized into 5 symptom clusters:

  1. Apathy (lack of initiative)
  2. Psychosis (delusions, hallucinations)
  3. Aggression/Agitation (verbal, physical)
  4. Hyperactivity (pacing, restlessness, disinhibition)
  5. Affective (dysphoria, elation irritability, anxiety)

Frequency of BPSD Symptoms in Alzheimer's

Adapted from: Lishman’s Organic Psychiatry (2007)
Symptoms Prevalence (%)
Misidentification syndrome 10-20
Depression 10-25
Hallucinations 20-30
Paranoid or delusional 20-30
Agitation 30-70
Wandering 15-40
Aggression 20-40
Anxiety >50
Apathy 15-80
Circadian rhythm disturbance 30-80

Theoretical models that explain the causes of BPSD include:

  1. Unmet Needs Model (i.e. - the patient is unable to express needs)
  2. Progressively Lowered Stress Threshold Model (i.e. - ability to deal with stress or stimuli is impaired)
  3. ABC Model (Antecedent-Behaviour-Consequence learning theory)

A broad differential diagnosis must be considered at all times:

BPSD Differential Diagnosis

Delirium Look for acute changes and fluctuations, and do a thorough delirium work up if suspected. Infections such as UTIs can be frequent culprits.
Depression Major depressive disorder can be difficult to identify in advanced dementia
Pain Pain is frequently underdiagnosed, one must be vigilant and look for verbal and non-verbal cues.[4] If pain is properly managed and treated, this can improve agitation, mood, apathy, appetite, and reduce nighttime behaviours.[5] However, treating pain does not change baseline irritability.

If pain is identified, a stepwise approach to treating pain is recommended, starting with:
1. Acetaminophen
2. Extended release morphine
3. Buprenorphine transdermal patch
4. Pregabalin[6]
Medical Triggers • Dehydration
• Constipation
• Urinary or chest infection
• Dental pain/infection
• Pain
Environmental Triggers Identify the presence of any enivronmental triggers, which can often worsen or exacerbate BPSD[7]
• Excessive noise or stimulation
• Lack of structure/routine
• Inadequate lighting
• Confusing surroundings
• Excessive demands
• Loneliness/boredom
• Behaviour of others

Also think about identifying the “4 B's” of discomfort in older adults:[8]

  1. Bowels: when was the patient’s last bowel movement
  2. Bladder: when did they last urinate? Any urinary symptoms?
  3. Beverage: are they hungry or thirsty? Have they been offered preferred beverages or food?
  4. Bottom (to Top): a visual survey for obvious precipitants of distress and agitation

Managing BPSD requires a thorough assessment, involving multiple sources of information, including a medical history, social history, personal history, and habits. Family and caregivers also need to be interviewed. There also needs to be an adequate physical exam, bloodwork, and urine cultures.

It can often be helpful to break down the BPSD into ABC (Antecedent, Behaviour, and Consequences) charting. This helps you identify if there are patterns to the behaviours, and allows the use of behavioural techniques to extinguish some behaviours, instead of medications. The key is to avoid positively reinforcing unwanted behaviours (e.g. - man screams and nurse soothes him, which leads to more screaming to seek soothing in the future) and encourage the reinforcement of alternate behaviours (e.g. - screaming man gets only attention when he is calm). The challenge with implementing these behavioural care plans is that all staff and caregivers have to be involved and follow the plan. Otherwise, intermittent reinforcement increases and worsens the behaviour.

Sample ABC Charting

Antecedent Behaviour Consequence
April 20, 8:00 PM Patient continuously asks to go to bathroom and calls for help Pulls of undergarment and urinates on floor Was told not to do this, brought to room, cleaned and changed
April 23, 8:30 PM Sitting at nursing station Asks to go to bathroom repeatedly, begins yelling for help RN engages patient, distracts and becomes quieter, until RN leaves, and the behaviour re-starts
April 27, 8:20 PM Sitting alone in corner Calls out “help” repeatedly Was asked what was wrong and staff spent some time with her until she calmed down, but then it started again

In this example, the antecedent is the patient is in situations where she frequently calls out for help and staff are not present. In order to extinguish this behaviour, she should be given more attention when she is calm, to reinforce the alternate behaviour.

Dementia Observational System (DOS)

Name Rater Description Download
Dementia Observational System (DOS) Observer/Clinician The Dementia Observational System (DOS) is a tool used to assess a person’s behaviour over a 24 hour cycle for up to 7 days to determine the occurrence, frequency, and duration of behaviours of concern. Download

The DICE Approach (Describe, Investigate, Create, Evaluate) is a model used to evaluate, manage, and treat BPSD, and to minimize the reflexive use of medications such as antipsychotics.[9][10] The evidence for non-pharmacological approaches to BPSD is better than the evidence for antipsychotics, and exceedingly better than for other classes of medication.

The DICE Approach

Kales, et al. Assessment and management of behavioral and psychological symptoms of dementia. BMJ 350.7 (2015)
Describe Patient, behavior, environment, situation, target
Investigate Medical problem, medications, caregiver causes, environment
Create Environment, behavioral, pharmacological interventions
Evaluate Effect, side-effects

Non-pharmacological interventions are a cornerstone of managing BPSD, and must not be forgotten! This includes physical exercises and activity programs, music therapy, therapeutic touch, bright light therapy, and aromatherapy.[11] The challenges with interpreting the efficacy of non-pharmacological interventions is they are often small in sample size, have no control groups, and have inadequate randomization. Other times, the interventions may be effective, but not financially feasible. The bottom line is that non-pharmacological treatments work, but there is no “one-size fits all” solution.

It is important that not all symptoms of BPSD respond to medications, and a comprehensive non-pharmacological approach must be taken!

Will the Symptoms Respond to Medications?

Symptoms and Medication Response

Usually not responsive to medications Can be responsive to medications
Simple wandering Sleep disturbances
Hiding Anxiety
Hoarding Dysphoria and depressive symptoms
Vocalizations Apathy/withdrawal
Inappropriate undressing Hyperactivity
Inappropriate defecation Hallucinations
Inappropriate urination Physical/verbal aggression
Repetitive activities Sexually inappropriate behaviour
Target the Symptoms

If there are symptoms that can be targeted and treated, the treatment should also target the specific symptoms:

  1. Apathy: bupropion, modafinil, memantine, psychostimulants, dopamine agonists
  2. Affect (dysphoria, irritability, anxiety): antidepressants, anticonvulsants
  3. Psychosis: antidepressants, antipsychotics
  4. Physical aggression: antipsychotics, memantine, antidepressants

Citalopram (best evidence), escitalopram, sertraline, and trazadone have comparable effects as antipsychotics, in reducing delusions, anxiety, and irritability/lability.[12] In the elderly, it is particularly important to monitor for hyponatremia, and sodium levels should be drawn within 4 weeks. Trazodone has inconclusive evidence,[13] though it is commonly used due to its sedating effects. There are some positive results in the use of trazodone for frontotemporal dementia.[14]

Antipsychotics are indicated only when there is a significant risk of harm to the patient or others or when the agitation or aggressive symptoms are persistent, recurrent, or severe enough to cause significant suffering and distress, or significant interference with provision of care.[15] There are clear risks for increased all-cause mortality and stroke risk when antipsychotics are used, and the benefits must outweigh the risks.[16] There is a 2-3 times increase in relative risk of cerebrovascular adverse event, and 1.7 times increase in risk of death. Although these are only relative risk increases (i.e. - the absolute risk of death is in fact quite low), it is important to obtain consent to treatment. The risk of death is highest for haloperidol, and lowest for quetiapine.[17] Antipsychotics also can bring on other side effects, including falls, metabolic side effects, hypotension, cognitive impairment, and pneumonia.

Risperidone (only one that has Health Canada approval), olanzapine and aripiprazole have the most evidence for severe agitation, aggression and psychosis associated with BPSD, where there is risk of harm to the patient and/or others. Quetiapine has conflicting evidence, as recent meta-analyses have found a strong placebo effect.[18] It can be tried in patients with parkinsonism (LBD or Parkinson's Disease (PD)).

Antipsychotic Dosing

Antipsychotic Starting dose (mg) Frequency Titrate by (mg) Maximum daily dose (mg) Notable side effects
Risperidone 0.25 daily/BID 0.25 2 EPS, gait disturbance, infection risk (UTI/URTI), peripheral edema, orthostatic hypotension, metabolic syndrome
Olanzapine 1.25 HS/BID 1.25-2.5 7.5 EPS, gait disturbance, infection risk (UTI/URTI), peripheral edema, metabolic syndrome
Loxapine 2.5 BID/TID 2.5-5 25 EPS
Haloperidol 0.25 daily/BID 0.25-0.5 2 EPS
Aripiprazole 0.5 daily 0.5-1 10 Insomnia, akathisia
Quetiapine* 12.5 BID/TID/HS 12.5-25 150 Orthostatic hypotension, sedation, QTc prolongation, agitation, insomnia

Typical Antipsychotics Are Contraindicated in Lewy Body Dementia

A severe sensitivity reaction occurs in an estimated 25-50% of Lewy Body Dementia (LBD) patients administered typical antipsychotic drugs (especially haloperidol) in the usual dose range.[19][20][21] This results in cognitive impairment, sedation, increased/irreversible acute onset of parkinsonism, or symptoms resembling neuroleptic malignant syndrome. If an antipsychotic must be used, then low potency atypical antipsychotics like clozapine or quetiapine should be used.[22]

There is currently insufficient evidence to recommend for or against the use of acetylcholinesterase inhbitors and/or memantine for the treatment of BPSD in Alzheimer's disease as a primary indication.[23] Many patients may already been on these medications as part of their disease treatment. There is, however, good first line evidence for the use of donepezil and rivastigmine in behavioural symptoms (especially hallucinations and agitation) related to Lewy Body Dementia (LBD).[24] It may also be helpful in managing symptoms of depression, anxiety, and apathy.

There is somewhat limited evidence for memantine, and prospective RCTs have been negative.

Carbamazepine been shown to have some utility in treating BPSD.[25] There is no evidence for valproic acid.

Other potential medications with some positive results include dextromethorphan-quinidine,[26] and prazosin.[27]

3) Cohen-Mansfield Agitation Inventory (CMAI), p. 2 1992