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 may 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 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 (visual > auditory)[4] 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


“Sundowning” is a phenomenon where disruptive behavior from BPSD worsens in the late afternoon.[5] It is thought to occur due to alterations in circadian rhythms from neurodegeneration. The reported prevalence of sundowning varies greatly between different clinical settings and various dementia types. It is also important to note that sundowning can also occur in delirium as well.

Agitation, disinhibition, and psychosis from BPSD are associated volume reduction and decreased metabolism in the dorsolateral prefrontal cortex, orbital prefrontal cortex, anterior cingulate, insula, and temporal lobes.[6] These are areas of the brain responsible for emotional regulation, self-awareness, and perception. Other cluster symptoms such as apathy are more associated with small vessel white matter disease. Importantly, there is no single cause for BPSD, and it is important to go beyond a biological approach. Biopsychosocial and holistic models that explain the causes of BPSD include:

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

Anytime you see or hear about a patient with “agitation” or “change in behaviour”, you must have a broad differential diagnosis at all times! Even if you've known the patient for a long time, if there is some new change in behaviour, you also need to make a new set of differentials.

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
Medications Have you considered whether there could be significant drug-drug interactions, or drug-related side effects that are causing behavioural changes? Always do a review of medications when considering changes in behaviours.
Pain Pain can be either acute or chronic, and is frequently under-diagnosed. One must be vigilant and look for verbal and non-verbal cues.[7] If pain is properly managed and treated, this can improve agitation, mood, apathy, appetite, and reduce nighttime behaviours.[8] However, treating pain does not change baseline irritability.

If pain is identified, a stepwise approach to treating pain is recommended, starting with:
1. Acetaminophen/NSAIDs
2. Extended release morphine
3. Buprenorphine transdermal patch
4. Pregabalin[9]
Medical Triggers • Dehydration (are they having adequate fluid or water intake?)
• Constipation (when was their last bowel movement?)
• Retention (are there are urinary retention issues?)
• Urinary tract or lung infections (any urinary symptoms, coughing, vital sign changes?)
• Dental pain, infection, abscesses (has there been an oral exam?)
• Ear pain, ear wax impaction, ear infection, abscesses (has there been an ear exam?)
• Musculoskeletal changes (imaging to rule out fractures, osteoporosis/degenerative changes, bed sores, or other soft tissue injuries?)
• Acute neurological insults (is there any facial droop or other neurological changes suggestive of a stroke?)
• Exacerbation of chronic conditions (could there be cancer progression?)
Environmental Triggers Identify the presence of any enivronmental triggers, which can often worsen or exacerbate BPSD[10]
• Excessive noise or stimulation
• Lack of structure/routine
• Inadequate lighting
• Confusing surroundings
• Excessive demands
• Loneliness/boredom
• Behaviour of others co-patients/residents
• Change in caregivers
• Vision (do they need glasses?) or hearing changes (do they have hearing aids?)
Personality • What was the individual's underlying temperament and personality before the behavioural changes? How much of this is their “baseline” self?


For an easy mnemonic to remember common triggers for behavioural changes, think about the 4 B's of discomfort in older adults:[11]
  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

Depending on the physical exam and patient's symptoms, common investigations may include: CBC, electrolytes, extended electrolytes, urine culture, and imaging (e.g. - chest X-ray).

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.

Daily information and measures that should be captured include:

  • The times medications are being administered for BPSD, and what response the individual has had to the medication
  • Overall fluid intake and oral intake
  • Bowel movements and urine output
  • Sleep charting or Dementia Observation Charting (DOS)
  • Vitals or orthostatic vitals
  • Pain monitoring (e.g. - with movement or feeding)

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 using 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.

  • It is not enough to just rely on subjective reports from nursing staff or physicians to determine a patient's level of agitation or behavioural changes
  • BPSD symptoms are subjective, and thus should be charted in as objective of a way as possible.
  • Thus, the Dementia Observational System (DOS) is an objective way of charting these behaviours
  • In facilities that do not do a DOS, sleep charting might also be ordered as well.

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.[12][13] 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,[14] music therapy, therapeutic touch, bright light therapy, and aromatherapy.[15] 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.

Antidepressants and antipsychotic medications are the most common medication classes used for BPSD. However, it is important to remember that not all symptoms of BPSD respond to medications, and a comprehensive non-pharmacological approach must be taken! If there are symptoms that can be targeted and treated pharmacologically, the medications should 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

Symptoms and likelihood of 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

Medication Classes for BPSD and Evidence

Medication/Class Evidence
Memantine • There is somewhat limited evidence for memantine, and prospective RCTs have been negative.
Acetylcholinesterase inhbitors (AChEI) • AChEIs are recommended as a treatment option for AD with cerebrovascular disease, dementia with Parkinson's disease, and mild to severe AD, but there is no recommendation for or against its use as a primary treatment for neuropsychiatric symptoms (i.e. - BPSD).[16] Many patients may already been on these medications as part of their disease treatment.
• There is good first line evidence for the use of donepezil and rivastigmine in behavioural symptoms (especially hallucinations and agitation) related to Dementia with Lewy Bodies (DLB).[17] It may also be helpful in managing symptoms of depression, anxiety, and apathy.
AChEI plus memantine • There is insufficient evidence to recommend for or against the combination of a ChEI and memantine together for neuropsychiatric symptoms of dementia.[18]
Mood stabilizers • Carbamazepine been shown to have some utility in treating BPSD.[19]
Valproic acid • Valproic acid should not be used for agitation and aggression in AD.[20][21]
Other • Other potential medications with some positive results include dextromethorphan-quinidine,[22] and prazosin.[23]
  • Citalopram (best evidence), escitalopram, sertraline, and trazodone have comparable effects as antipsychotics, in reducing delusions, anxiety, and irritability/lability.[24]
  • In the elderly, it is particularly important to monitor for hyponatremia, and sodium levels should be drawn within 4 weeks. Trazodone has inconclusive evidence,[25] though it is commonly used due to its sedating effects. There are some positive results in the use of trazodone for frontotemporal dementia.[26]
  • Mirtazapine is not an effective agent for treatment of BPSD, and may be associated with increased mortality risk.[27]
  • Risperidone (the 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 recently had conflicting evidence, as recent meta-analyses have found a strong placebo effect.[28]
  • Quetiapine and clozapine are they only antipsychotics that can be used in patients with parkinsonism (DLB or Parkinson's).
  • Antipsychotics are only indicated 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.[29]
  • There are clear risks for increased all-cause mortality and stroke risk when antipsychotics are used, and the benefits must outweigh the risks.[30] 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 for treatment. The risk of death is highest for haloperidol, and lowest for quetiapine.[31] Antipsychotics also can bring on other side effects, including falls, metabolic side effects, hypotension, cognitive impairment, and pneumonia.

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 and High Potency Antipsychotics Are Contraindicated in Lewy Body Dementia and Parkinson's

A severe sensitivity reaction occurs in an estimated 25-50% of Dementia with Lewy Bodies (DLB) patients administered typical antipsychotic drugs (especially haloperidol) in the usual dose range.[32][33][34] 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.[35]

Inappropriate sexual behavior (ISB) can be an extremely disruptive form of BPSD, placing other individuals at risk, and cause distress for caregivers. No randomized control trials have investigated the use of treatment of ISB, but several different classes have been used.


Adapted from: De Giorgi, R. et al. (2016). Treatment of inappropriate sexual behavior in dementia. Current treatment options in neurology, 18(9), 41.
Approach Description
Environmental Switching from a female to a male staff member, single rooms, and redirection may be helpful in mild cases.
Behavioural Consistent redirection and enhanced communication, distraction techniques (crafts, social activities), use of clothing with back zippers (can have ethical implications)
Education Caregiver education about sexuality, and changes associated with dementia can help.

Pharmacological (Psychotropics)

Adapted from: De Giorgi, R. et al. (2016). Treatment of inappropriate sexual behavior in dementia. Current treatment options in neurology, 18(9), 41.
Psychotropics Description
Antidepressants • SSRIs are common first line agents.
• Tricyclic antidepressants, specifically clomipramine
• Trazodone
Anxiolytics There is no evidence for the use of benzodiazepines in ISB, it may cause paradoxical reactions, and may worsen cognitive impairment.
Antipsychotics • Quetiapine
• Haloperidol
Anticonvulsants • Gabapentin
• Carbamazepine
Cholinesterase inhibitors • Donepezil

Pharmacological (Hormonal and Antiandrogen)

Adapted from: De Giorgi, R. et al. (2016). Treatment of inappropriate sexual behavior in dementia. Current treatment options in neurology, 18(9), 41., and Joller P. et al. Approach to inappropriate sexual behaviour in people with dementia. Can Fam Physician. 2013;59(3):255-260.
Hormonal and antiandrogen agents Mechanism of action Dosing Potential adverse effects
Medroxyprogesterone (MPA)[36][37] Indirectly decreases the level of testosterone by inhibiting the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). • MPA 100 to 500 mg IM weekly, or
• MPA 100mg PO daily
Fatigue, weight gain, hot or cold flashes, depression, elevated blood glucose, insomnia
Cyproterone acetate (CPA)[38] Synthetic progestin and antiandrogen that blocks androgen receptors CPA 10 to 50mg PO daily Gynecomastia, galactorrhea, worsening diabetes control, depression, osteoporosis, adrenal insufficiency on withdrawal, hepatotoxicity (liver enzymes should be checked first)
Finasteride[39] 5α-reductase inhibitor that blocks conversion of testosterone to dihydrotesterone Finasteride 5mg PO daily Gynecomastia, testicular pain, depression
Estrogen[40] Estrogens inhibit the secretion of LH and FSH, and decrease testosterone production. • Estrogen (conjugated) 0.625 mg PO daily, or
• Transdermal estrogen patch 0.5 to 0.10 mg daily
Weight gain, depression, gynecomastia, venous thromboembolism (VTE)
Leuprolide[41] Leuprolide is a gonadotropin-releasing hormone (GnRH) analog. It suppress testosterone
production by stimulating the secretion of pituitary LH and FSH, with subsequent increase in estrogen levels and decrease of testosterone
Leuprolide acetate 7.5 mg IM qmonthly Weight gain, bone pain, osteoporosis, mood changes, pituitary apoplexy (rare)
Spironolactone[42] Potassium-sparing diuretic with anti-androgenic properties, via blocking of androgen receptors Spironolactone 75mg PO daily Hyperkalemia, gynecomastia, change in hair growth, upper gastrointestinal ulcers, agranulocytosis

Behavioural and Psychological Symptoms of Dementia (BPSD) Guidelines

Guideline Location Year PDF Website
British Columbia Best Practice Guideline for
Accommodating and Managing
Canada 2012 Link Link
Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD) Canada 2020 - Link
Canadian Coalition for Seniors' Mental Health (CCSMH) Assessment and Treatment of Mental Health Issues in Long-Term Care Canada 2006, 2014 2006 Guideline
2014 Update
National Institute for Health and Care Excellence (NICE) UK 2018 - Link
Treatment of Inappropriate
Sexual Behavior in Dementia
UK 2016 - Link
American Psychiatric Association (APA) USA 2016 - Link (Bruyère Research Institute) and University of Sydney Deprescribing Guidelines International 2018 - Link
3) Cohen-Mansfield Agitation Inventory (CMAI), p. 2 1992