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.

Prevalence

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:

Apathy (lack of initiative)
Psychosis (delusions, hallucinations)
Aggression/Agitation (verbal, physical)
Hyperactivity (pacing, restlessness, disinhibition)
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

“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:

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

See also main articles: Delirium, Pain Medicine, and Major Depressive Disorder (MDD)

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?

Mnemonic

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

Bowels: when was the patient’s last bowel movement?
Bladder: when did they last urinate? Any urinary symptoms?
Beverage: are they hungry or thirsty? Have they been offered preferred beverages or food?
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).

See also: Davies, S. J. et al. (2018). Sequential drug treatment algorithm for agitation and aggression in Alzheimer’s and mixed dementia. Journal of Psychopharmacology, 32(5), 509-523.

Managing BPSD requires a thorough assessment, involving multiple sources of information, including a medical history, social history, personal history, and habits. All medications must be reviewed, and its role and indication reassessed. Family and caregivers also need to be interviewed. There also needs to be an adequate physical exam, bloodwork, and urine cultures if appropriate.

Neuropsychiatric scales to assess behaviours and symptoms are critical to ensuring the symptoms are properly tracked and documented, to track changes before and after a treatment plan. Either the Cohen-Mansfield Agitation Inventory (CMAI) or Neuropsychiatric Inventory (NPI) should be completed for any patient experiencing BPSD.

BPSD Scales

Name	Rater	Description	Download
Cohen-Mansfield Agitation Inventory (CMAI)	Clinician/Caregiver	The CMAI is a 29-item scale to systematically assess agitation and neuropsychiatric behaviours in dementia. Each item is rated on a 7-point scale ranging from “Never” to “Several times per hour”.	Download
Neuropsychiatric Inventory (NPI)	Clinician	The Neuropsychiatric Inventory (NPI) is the original interview developed to provide a means of assessing neuropsychiatric symptoms and psychopathology of patients with Alzheimer’s disease and other neurodegenerative disorders.	Download
Neuropsychiatric Inventory Nursing Home Version (NPI-NH)	Clinician/Caregiver	The NPI-NH was derived from the Neuropsychiatric Inventory (NPI), which was originally developed for the assessment of neuropsychiatric symptoms and psychopathology in community-dwelling patients where information was obtained from family caregivers. The content of the questions of the NPI and NPI-NH are identical but have been rephrased appropriately for caregivers.	Download
Neuropsychiatric Inventory-Questionnaire (NPI-Q)	Clinician/Caregiver	The NPI-Q is a questionnaire completed by informants. The NPI-Q differs from the standard NPI in several ways. It is given as a 2-page self-administered questionnaire, as opposed to an interview. The NPI-Q is designed to be completed within 5 minutes.	Download

Daily information and measures that should be captured during each visit with a patient with BPSD should include:

The times medications are being administered for BPSD, and what response the individual has had to the medication
Overall oral (solids and liquids) intake
Bowel movements and urine output
Sleep charting or Dementia Observation Charting (DOS)
Vitals and/or orthostatic vitals
Pain monitoring (e.g. - with movement or feeding)
Overall amount of as needed (prn) medication use
Review of overnight and previous day's behaviours with staff

See also main article: Behavioural Modification

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.

See also: Behavioural Supports Ontario: Dementia Observation System (BSO-DOS©) Tool Kit

The Dementia Observational System (DOS) is an objective way of charting dementia behaviours
In facilities that do not do a DOS, sleep charting might also be ordered as well.
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, and this is where the value of the DOS comes in.
BPSD symptoms are subjective, and thus should be charted in as objective of a way as possible.

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	Thoroughly describe and accurately characterize the symptoms and the contexts in which they occur. This description should come from a discussion with the caregiver and the person with dementia (if possible). For example, if the behavior is agitation, it's important to determine the actual behaviour) (e.g. - did the patient strike the caregiver during a bath? Was the water too hot? How was the caregiver talking to and approaching the patient?
Investigate	Once the symptoms are clearly described, the clinician then needs to identify, or exclude, possible underlying and modifiable causes. These can include unmet needs (e.g. - fear, insufficient sleep, a need for eyeglasses or hearing aids), or acute medical problems (e.g. - anemia, urinary tract infection, or constipation). Current medications should be evaluated, and blood tests and urinalysis ordered if needed. Poor sleep habits and boredom also should be considered, along with the any caregiver's relationship with the patient, including caregiver stress or depression that could exacerbate the patient's behaviours.
Create	In this step everyone collaborates to create and implement a treatment plan. Treatments can be either non-pharmacologic (behavioural, environmental, or a combination) or pharmacologic. Priority should be given to treating physical problems, such as antibiotics for a urinary tract infection, or discontinuing drugs that cause behavioural side effects. Providers should brainstorm behavioural and environmental approaches with caregivers and other members of the care team, which could include a visiting nurse or occupational therapist. The 5 domains of general strategies include: (1) educating the caregiver; (2) improving communication between the caregiver and patient; (3) creating meaningful activities for the patient; (4) simplifying tasks and establishing structured routines; and (5) ensuring safety and enhancing the environment.
Evaluate	The final step is to evaluate whether the strategies have been implemented and have had the desired effects. Since behaviours fluctuate over the course of dementia, ongoing monitoring is essential: Caregivers can learn triggers for unwanted behaviors and to learn to spot these triggers before the symptoms fully develop.

See also: P.I.E.C.E.S. Step-by-Step Video

P.I.E.C.E.S. (Physical. Intellectual. Emotional. Capabilities. Environment. Social.) is a non-pharmacological assessment tool used by healthcare professionals to help them determine causes for behavioural and psychological symptoms associated with dementia. In brief, in P.I.E.C.E.S., the key questions to ask are:

What are the priority concerns; is it a change for the Person?
- For each priority concern(s), ask; is it a change for the Person?
- Avoid making assumptions and moving too quickly to actions before having a shared understanding
- Language has to be clear, respectful, and objective
- Priority concerns will vary over time; what are we seeking to understand now?
What are the RISKS and possible contributing factors (PIECES)?
- R - Roaming (e.g. searching, seeking exit)
- I - Imminent harm (Frailty, Falls, Fire, Firearms)
- S - Suicide Ideation
- K - Kinship relationships (risk of harm by the Person or to the Person by others; including avoidance of the Person)
- S - Substance use
- S - Self-neglect (a person's capability to care for self, for which there could be many contributing factors)
- S - Safe Driving
- S - Security
What are the actions?

P.I.E.C.E.S.

P - Physical causes for behaviours	There are a number of possible physical causes that may trigger a behaviour so time is required to eliminate or at least determine which, if any, of the following physical elements might be causing a reaction: • Pain (such as arthritis). • Sensory loss (poor eyesight, poor hearing). • Difficulty walking. • Temperature – cold, hot. • Medication – what are they taking – anything new or anything recently discontinued?
I - Intellectual causes for behaviours	Due to the impact dementia has on the brain, there are intellectual impairments that individuals with dementia deal with that can cause agitation or other behaviours. Healthcare professionals refer to them as the Seven A’s which help explain the frustration a patient faces: 1. Anosognosia is the lack of insight or awareness. The person with dementia does not know they have dementia and they believe they are fine. “There’s nothing wrong with me.” 2. Amnesia is the loss of memories such as facts, experiences or information. The patient may know who they are but has trouble learning new information or forming new memories. 3. Altered Perception is the inability to recognize themselves – their own reflection. Living in the past – living 25 years in the past becomes their reality. 4. Aphasia is a problem with language. There are four kinds: (1) Expressive: know what you want to say but can’t say what you mean, (2), Receptive: hear the voice or see the print but can’t make sense of the words, (3) Anomic: trouble using the correct word for places, object or events, (4) Global: can’t speak, understand speech, read or write. 5. Apathy is the absence or suppression of interest or motivation. 6. Agnosia is the loss of the ability to recognize objects, faces, voices or places, but still have an ability to think, speak and interact with the world normally. 7. Apraxia is a motor speech disorder where messages from the brain to the mouth are disrupted. The person is unable to move their mouth, lips or tongue to the right place to make sounds correctly even though their muscles are not weak.
E - Emotional causes for behaviours	How is the person feeling in their body? Potential emotional causes for behavioural issues include anxiety and depression. Everyone has a baseline level of anxiety they can withstand. For a person with dementia, their perceptual disconnect impacts their threshold for anxiety. Their world can be frightening which heightens their state of anxiety. If you imagine that the objects they see are distorted, language doesn’t sound the same, or they may not recognize their own reflection, this altered state can impact their mood which in turn affects their behaviours. Anxiety is fueled by the fact that an individual with dementia has no control over their world – they can no longer navigate their time. Instead, they must rely on others to decide their day and schedule their activities for them. Behaviour(s) caused by anxiety may include being in a general state of upset or shadowing (following the caregiver around constantly).
C - Capabilities (How they affect behaviour)	Caregivers need to assess what the individual with dementia is and is not capable of doing and then create opportunities for him or her to help themselves. On some level the individual with dementia is aware of their limitations, but if you need to replace some objects with unbreakable ones, make them as safe and ‘adult’ as possible – not childish. There is a risk of caregivers doing too much for the person with dementia. Don’t assume they can’t do things for themselves. Tasks may take longer and they may not remember the order of things but they are still able to perform acts such as dressing themselves. Create a list with the proper order of garments, put it on the wall, and point to the list so your loved one can follow it and dress themselves. If followed repeatedly, day after day, their “procedural body memory” will take over and your loved one will look for the list to get dressed. It can become a routine, but this requires consistency.
E - Environment (How does their environment affect behaviour?)	Take a fresh look around the environment, and think about the following: • Eliminate clutter. • Create clear, open and safe spaces to walk around in and be able to touch things without fear. • Is it too hot or too cold? Check the room and water temperature. • Is the room properly lit? Is it too bright, or too dark? Be aware that darkness can create shadows. Shadows can be frightening and may increase falls. • Too many people or too much noise can cause confusion and anxiety, which can manifest as a behaviour such as shouting or agitation.
S - Social (How does social activity affect behaviour?)	The social aspect is all about the person – who they were. It’s very important. A person with dementia may not be able to express themselves as they once did, but their ‘person’ has not left with the disease. The Montessori method for dementia programming can be very effective for working with patients – the method’s philosophy is: We define ourselves by the activities we do. The activities are important, but the ability to have activities that hold meaning for us is very important. The challenge is to create opportunities that still have meaning for the person with dementia when their cognitive abilities are compromised. It requires planning, careful observation and thought. The most effective interventions are built on ‘who’ the person was. So, the best thing you can do for your loved one with dementia is to create a document that tells other people who your loved one was. It should include the highlights, low moments and difficulties faced throughout their lives.

See also: Watt, J. A. et al. (2019). Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network meta-analysis. Annals of internal medicine, 171(9), 633-642.

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:

Apathy: bupropion, modafinil, memantine, psychostimulants (amphetamine, methylphenidate), dopamine agonists
Affect (dysphoria, irritability, anxiety): antidepressants (SSRIs, SNRIs, trazodone), anticonvulsants (carbamazepine, pregabalin, gabapentin)
Psychosis: antipsychotics (risperidone), antidepressants (SSRIs, SNRIs)
Physical aggression: antipsychotics (risperidone), memantine, antidepressants (SSRIs, SNRIs)

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
Trazodone	• Trazodone may help decrease insomnia, but it should be used with caution given the risk for orthostatic hypotension.^[16] • Citalopram (best evidence), escitalopram, sertraline, and trazodone have comparable effects as antipsychotics, in reducing delusions, anxiety, and irritability/lability.^[17] • In the elderly, it is particularly important to monitor for hyponatremia, and sodium levels should be drawn within 4 weeks. Trazodone has inconclusive evidence,^[18] though it is commonly used due to its sedating effects. There are some positive results in the use of trazodone for frontotemporal dementia.^[19] • Mirtazapine is not an effective agent for treatment of BPSD, and may be associated with increased mortality risk.^[20]
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).^[21] 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).^[22] 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.^[23]
Mood stabilizers	• Carbamazepine been shown to have some utility in treating BPSD.^[24]
Valproic acid	• Valproic acid should not be used for agitation and aggression in AD.^[25]^[26]
Benzodiazepines	Evidence for the efficacy of benzodiazepines in BPSD is poor. There are few studies that show its efficacy. Benzodiazepines are associated with sedation, dizziness, falls, worsening cognition, respiratory depression, dependency and paradoxical disinhibition in the elderly.^[27]
Other	• Other potential medications with some positive results include dextromethorphan-quinidine,^[28] and prazosin.^[29]
Nabilone	Nabilone may be effective in reducing agitation, but caution is warranted as it may cause excessive sedation and cognitive impairment.^[30]

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.^[31]
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.^[32]
There are clear risks for increased all-cause mortality and stroke risk when antipsychotics are used, and the benefits must outweigh the risks.^[33] 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.^[34] 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

*Quetiapine has conflicting evidence. It can be tried in patients with Parkinsonism, Lewy body dementia, or Parkinson's

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.^[35]^[36]^[37] 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.^[38]

See also: Joller P. et al. Approach to inappropriate sexual behaviour in people with dementia. Can Fam Physician. 2013;59(3):255-260.

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.

Non-pharmacological

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)^[39]^[40]	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)^[41]	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^[42]	5α-reductase inhibitor that blocks conversion of testosterone to dihydrotesterone	Finasteride 5mg PO daily	Gynecomastia, testicular pain, depression
Estrogen^[43]	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^[44]	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^[45]	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 BPSD	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	Link
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
Deprescribing.org (Bruyère Research Institute) and University of Sydney Deprescribing Guidelines	International	2018	-	Link