Managing Behavioral and Psychological Symptoms of Dementia

Mar 20, 2020

BPSD is associated with worse outcomes for patients with dementia. Management is not standardized, but protocols generally involve the treatment of underlying symptoms followed by the use of nonpharmacological management techniques and evidence-based pharmacotherapy for refractory BPSD.


Alzheimer disease and other dementias are a major and increasing global health challenge. In 2010 there were 35.6 million individuals living with dementia and their numbers are expected to double every 20 years and reach approximately 115.4 million by 2050.1

Behavioral and psychological symptoms of dementia (BPSD) is used to describe a group of diverse non-cognitive symptoms and behaviors that are frequently seen among individuals with dementia. BPSD affects approximately 90% of individuals at some point during the course of the illness, with greater prevalence noted among individuals receiving skilled care.2

Common BPSD include apathy, anxiety, depression, agitation, psychosis, sleep disturbances, dysphoria, aberrant motor activity, hallucinations and delusions. There is emerging evidence that specific symptom patterns can be identified in different types of dementias. One recent study found that hallucination, abnormal motor behavior, and anxiety were significantly more frequent in Alzheimer disease (AD) and mixed dementia (MD) compared with vascular dementia (VD).3 Hallucinations and delusions were significantly more severe in AD and MD . Disinhibition was significantly more frequent and severe and agitation was significantly more severe in patients with VD.

BPSD is associated with faster cognitive decline, greater functional impairment, reduced quality of life for patients and their caregivers. BPSD is also a risk factor for earlier institutionalization among individuals with dementia. Moreover, BPSD adds to the overall cost of caring for individuals with dementia.

This spectrum of symptoms is thought to occur due to the complex interaction between biological, psychological, social, and environmental factors. These factors include structural, functional, and neurochemical changes in the brain, underlying medical or psychiatric disorders, preexisting personality traits, caregiver distress/depression, and misleading or lack of stimuli from the environment.


When an individual is being assessed for BPSD, it is vitally important to collect information from the caregivers of these individuals. Collateral information will provide insight into the type and duration of symptoms, aggravating and mitigating factors, prognostic factors, and a history of interventions that have been beneficial in managing BPSD. Underlying medical and psychiatric conditions should be evaluated and appropriately managed as these might be precipitating and/or worsening the BPSD. A thorough medication review will help eliminate the effect of medications, which may cause and/or aggravate the BPSD. This is also true of any illicit substances.

An assessment of BPSD includes the use of standardized and validated assessment scales such as the Neuropsychiatry Inventory (NPI) or the Behavioral Pathology in Alzheimer Disease Rating Scale (BEHAVE-AD). These standardized tools can assist in qualifying and quantifying the BPSD. They can also assist with tracking the progression of BPSD and the efficacy of interventions.


Both nonpharmacological and pharmacological management strategies have been found to be beneficial among individuals with BPSD. Among the nonpharmacological strategies, music therapy and behavioral management techniques appear to be effective for reducing the BPSD.4 These interventions have been shown to reduce the frequency and severity of the BPSD and also decrease caregiver burden with effect sizes similar to those of associated with pharmacotherapy.5

To be successful nonpharmacological interventions need to be individualized and delivered in a caring way in a caring environment.6 Nonpharmacological interventions that targets both the patient and the provider improves the lives of both partners in the dyad.

Nonpharmacological management strategies are often used prior to or in conjunction with pharmacotherapy. This is done to minimize the exposure of individuals with BPSD to pharmacotherapeutic agents, given their significant adverse effect profile.

Although there are no FDA-approved medication classes to manage BPSD, many medications have been tested.7 Common medication classes that have been used in the management of BPSD include antidepressants, antipsychotics, anticonvulsants ,and cholinesterase inhibitors.

Findings from a meta-analysis indicates that only two medications had statistically significant higher response rates than placebo in the management of BPSD: dextromethorphan/quinidine [odds ratio (OR) = 3.04] and risperidone (OR =1.88) respectively.8 Dextromethorphan/quinidine and risperidone were also found to be superior to haloperidol and quetiapine. Haloperidol failed to demonstrate higher efficacy than placebo (OR = 0.86), and it was less efficacious compared with nearly all medications in the network. No individual SSRI was found to have significantly greater efficacy than placebo. There were non-significant differences in treatment acceptability for nearly all medications when compared with placebo, except for oxcarbazepine (OR = 3.73). Oxcarbazepine also had inferior acceptability when compared with donepezil and haloperidol.

Data from a second meta-analysis show that compared with placebo, aripiprazole, quetiapine, and risperidone were associated with improvements in symptoms on different standardized rating scales (Table).9 However, the differences between the atypical antipsychotics were not significant for effectiveness, death, or cerebrovascular events. Compared with placebo, risperidone (OR = 3.85) and olanzapine (OR = 4.28) were associated with increased risk for cerebrovascular events.

A multidisciplinary team from Canada created an evidence-based algorithm for the management of BPSD.10 After a baseline assessment and the discontinuation of potentially exacerbating medications they recommend sequential trials using risperidone, aripiprazole or quetiapine, carbamazepine, citalopram, gabapentin, and prazosin, if pharmacotherapy is indicated.

A recent expert panel consensus recommended a step-wise approach to the management of BPSD.11 The panel recommendation is that management commence with the identification of underlying causes for BPSD. This should be followed by the implementation of nonpharmacological management strategies including caregiver training, environmental adaptations, person-centered care, and tailored activities. If pharmacologic interventions are required, the use of citalopram and analgesia should be given priority before other medication classes especially antipsychotics. For the management of psychosis, risperidone could be used after the evaluation and management of underlying causes for the psychosis.

In addition, emerging data indicate the efficacy of cannabinoid and electroconvulsive therapy (ECT) for the management of BPSD.12,13 Other treatments that are being studied include pimavanserin, lithium, gabapentin, mirtazapine, escitalopram, carbamazepine, and methylphenidate.14


BPSD is associated with worse outcomes for patients with dementia. The management of patients is not standardized, but protocols generally involve the treatment of underlying symptoms followed by the use of nonpharmacological management techniques and evidence-based pharmacotherapy for refractory BPSD. When using antipsychotic medications, caution is advised given their significant adverse effect profile. Treatment outcomes among individuals with BPSD can be improved by using a risk to benefit analysis and step-wise approach to management.


Dr Tampi is Chairman, Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, and Chief, Section of Geriatric Psychiatry, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Ms Tampi is Executive Vice President, Diamond Healthcare, Richmond, VA. The authors report no conflicts of interest concerning the subject matter of this article.


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