Summary

Behavioural and Psychological Symptoms of Dementia (BPSD) refers to a range of non-cognitive symptoms affecting people with dementia, including agitation, aggression, wandering, sleep disturbance, depression, anxiety, psychosis (hallucinations and delusions), apathy, and sexually inappropriate behaviour. BPSD affects up to 90% of dementia patients at some point and is a major cause of distress for patients, carers, and staff. The first step in management is always to identify and treat underlying causes (pain, infection, constipation). Non-pharmacological approaches are first-line. Antipsychotics (e.g., risperidone) are used cautiously for severe symptoms due to increased risk of stroke and mortality.

Key Facts

• Prevalence: Up to 90% of dementia patients at some stage
• Symptoms: Agitation, Aggression, Wandering, Psychosis, Depression, Apathy, Sleep disturbance
• First Step: Rule out delirium, pain, infection, constipation
• First-Line: Non-pharmacological interventions
• Medication: Risperidone (short-term, lowest dose) — increased stroke/mortality risk
• Assessment: Cohen-Mansfield Agitation Inventory

Clinical Pearls

"Always Think: Pain, Infection, Constipation": Behaviour change in dementia often reflects an unmet need. Rule out medical causes first.

"Delirium on Dementia": A sudden change in behaviour in a dementia patient is delirium until proven otherwise. Look for infection, medication changes, urinary retention.

"Low and Slow": If antipsychotics are needed, use the lowest effective dose for the shortest possible time. Risperidone is licensed for BPSD.

"Antipsychotics Carry Risk": Antipsychotics increase mortality and stroke risk in dementia. Document the discussion with patient/family.

General

• Assess for pain (facial expressions, guarding)
• Signs of infection (fever, cough, dysuria)
• Hydration and nutrition

Mental State

• Cognitive assessment (worsening dementia or delirium?)
• Mood
• Psychotic symptoms

Physical

• Abdominal examination (constipation, urinary retention)
• Chest examination
• Review medication chart

Natural History

• BPSD fluctuates over time
• Some symptoms improve spontaneously
• Often worsens with disease progression

Impact

• BPSD is more distressing to carers than cognitive decline
• Major reason for care home admission

Key Guidelines

1. NICE NG97: Dementia (2018)
2. Maudsley Prescribing Guidelines: Dementia

Key Evidence

Antipsychotics

• CATIE-AD, DART-AD trials showed modest efficacy but increased mortality
• Use only when severe risk; short-term

Non-Pharmacological

• Growing evidence for person-centred care, music therapy

What is BPSD?

BPSD stands for "Behavioural and Psychological Symptoms of Dementia." It includes things like agitation, aggression, wandering, depression, anxiety, and sometimes seeing or believing things that aren't there.

Why Does It Happen?

People with dementia may not be able to tell us when something is wrong. Changes in behaviour are often a sign of an unmet need — pain, hunger, needing the toilet, or just feeling scared or bored.

How is It Managed?

• First: Rule out medical problems (infection, pain, constipation)
• Non-drug approaches come first: Calm environment, activities, music, familiar routines
• Medications (like risperidone) are used only as a last resort because they carry risks

What Should Carers Do?

• Stay calm and reassuring
• Try to understand the person's needs
• Create a calm environment
• Report any sudden changes to your GP