Behavioural and Psychological Symptoms of Dementia (BPSD)

1. Clinical Overview

Summary

Behavioural and Psychological Symptoms of Dementia (BPSD) refers to a heterogeneous range of non-cognitive symptoms and behaviours that occur in patients with dementia. These include agitation, aggression, wandering, sleep disturbance, depression, anxiety, psychosis (hallucinations and delusions), apathy, disinhibition, and sexually inappropriate behaviour. BPSD affects up to 90% of dementia patients at some point during their illness trajectory and represents a major source of distress for patients, caregivers, and healthcare staff. [1,2]

The cornerstone of BPSD management is the systematic identification and treatment of reversible underlying causes, particularly pain, infection (especially urinary tract infections and pneumonia), constipation, medication side effects, and environmental triggers. [3,4] Non-pharmacological interventions constitute first-line management and include person-centered care, environmental modifications, music therapy, aromatherapy, and structured activities. [5,6] Pharmacological interventions, particularly antipsychotics such as risperidone and quetiapine, are reserved for severe symptoms where there is risk to the patient or others, and must be used with extreme caution due to increased risks of stroke, parkinsonism, sedation, falls, and mortality. [7,8]

BPSD is the primary driver of caregiver burden—more so than cognitive decline—and is the leading reason for nursing home placement in dementia patients. [9] A person-centered, multidisciplinary approach using frameworks such as DICE (Describe, Investigate, Create, Evaluate) optimizes outcomes while minimizing medication-related harm. [10]

Key Facts

• Prevalence: 60-90% of dementia patients experience BPSD at some stage; increases with disease severity [1,2]
• Symptoms: Agitation (40-60%), Apathy (50-70%), Depression (30-50%), Psychosis (20-40%), Wandering (20-40%) [2]
• First Step: Always rule out delirium, pain, infection (UTI, pneumonia), constipation, urinary retention, medication side effects [3,4]
• First-Line Management: Non-pharmacological interventions (person-centered care, music therapy, environmental modification, structured activities) [5,6]
• Pharmacological Management: Antipsychotics (risperidone 0.25-1mg/day) reserved for severe agitation/psychosis with risk; increased stroke and mortality risk [7,8]
• Assessment Tools: Neuropsychiatric Inventory (NPI), Cohen-Mansfield Agitation Inventory (CMAI) [11]
• Acetylcholinesterase Inhibitors: May reduce BPSD in Alzheimer's disease [12]
• Special Population: Severe neuroleptic sensitivity in Lewy body dementia—avoid typical antipsychotics entirely [13]

Clinical Pearls

"Always Think: Pain, Infection, Constipation": Behaviour change in dementia often reflects an unmet physical need. A systematic search for medical causes must precede any pharmacological intervention. [3,4]

"Delirium on Dementia": A sudden or acute change in behaviour in a patient with established dementia is delirium until proven otherwise. Look for infection (UTI, pneumonia, cellulitis), medication changes (anticholinergics, benzodiazepines), urinary retention, constipation, or acute illness. [3]

"Low and Slow": If antipsychotics are deemed absolutely necessary after exhausting non-pharmacological approaches, use the lowest effective dose for the shortest possible duration (ideally ≤6 weeks). Risperidone is the only antipsychotic licensed for BPSD in the UK (for up to 6 weeks). [7,8]

"Black Box Warning": Antipsychotics carry a black box warning for increased mortality and stroke risk in elderly patients with dementia. The number needed to harm for stroke is approximately 53-100 patients. [7,8] Document the risk-benefit discussion with the patient (if capacity permits) and family.

"Lewy Body Dementia = No Typical Antipsychotics": Patients with Lewy body dementia exhibit severe neuroleptic sensitivity reactions, including acute parkinsonism, sedation, confusion, and increased mortality. If antipsychotic treatment is unavoidable, use quetiapine at the lowest dose (12.5-50mg) with extreme caution. [13]

"Caregiver Burden Drives Institutionalization": BPSD, not cognitive impairment, is the primary predictor of nursing home placement. Supporting caregivers and optimizing BPSD management can prolong community living. [9]

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2. Epidemiology

Prevalence and Incidence

BPSD is nearly universal in dementia, with studies reporting prevalence rates of 60-90% over the course of the illness. [1,2] The prevalence increases with dementia severity, approaching 90% in moderate-to-severe dementia. [2]

Symptom-Specific Prevalence

Individual BPSD symptoms vary in frequency: [2]

Exam Detail: ### Dementia Subtype Differences

BPSD profiles differ by dementia subtype: [2,13]

Exam Viva Tip: If asked about hallucinations in dementia, remember that visual hallucinations are characteristic of Lewy body dementia, whereas auditory hallucinations are more typical of primary psychiatric disorders. [13]

Impact on Caregivers and Healthcare Systems

BPSD is the primary driver of caregiver burden, surpassing the impact of cognitive decline. [9] Studies show that:

• BPSD is the leading reason for nursing home placement in dementia patients [9]
• Caregiver depression and burnout are directly proportional to BPSD severity [9]
• Healthcare costs associated with BPSD management exceed those of cognitive symptoms [9]
• Emergency department visits and acute hospitalizations are often precipitated by BPSD crises [9]

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3. Aetiology and Pathophysiology

Multifactorial Model of BPSD

BPSD arises from a complex interaction of neurobiological, psychological, medical, and environmental factors. [1,2] The prevailing model conceptualizes BPSD as the result of:

1. Neurodegenerative brain changes (reduced cholinergic, serotonergic, and dopaminergic neurotransmission; frontal and temporal lobe atrophy)
2. Unmet needs (pain, hunger, thirst, toileting, social isolation, boredom)
3. Environmental triggers (overstimulation, noise, unfamiliar surroundings, changes in routine)
4. Medical precipitants (infection, constipation, medication side effects, delirium)
5. Premorbid personality and coping strategies

Exam Detail: ### Neurobiological Basis

The neurobiological underpinnings of BPSD vary by symptom domain: [2,14]

Acetylcholine Deficiency: Cholinergic deficits, particularly in Alzheimer's disease, are implicated in psychosis and agitation. [12] This provides the rationale for acetylcholinesterase inhibitor therapy (donepezil, rivastigmine, galantamine), which may attenuate BPSD. [12]

Reversible and Treatable Causes

A critical principle in BPSD management is the systematic exclusion of reversible medical causes. [3,4] BPSD is often a non-specific manifestation of underlying medical illness or unmet needs:

Clinical Pearl: "The Non-Verbal Patient": Patients with advanced dementia often cannot communicate pain or discomfort verbally. Instead, they express distress through behavioral changes—agitation, aggression, refusal of care, or withdrawal. A trial of regular analgesia (e.g., paracetamol 1g QDS) is both diagnostic and therapeutic. [4]

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4. Clinical Presentation

Symptom Domains

BPSD encompasses a wide spectrum of symptoms, which can be categorized into behavioral and psychological domains:

Behavioral Symptoms

Psychological Symptoms

Exam Detail: ### "Sundowning" Phenomenon

Sundowning refers to the worsening of confusion, agitation, and restlessness in the late afternoon and evening hours. [2] The exact mechanism is unclear, but hypotheses include:

• Circadian rhythm disruption
• Fatigue after a day of activity
• Reduced environmental cues (darkness)
• Hunger or discomfort

Management strategies include:

• Increasing light exposure during the day
• Structured activities in the morning and early afternoon
• Limiting caffeine and daytime napping
• Calm, predictable evening routine

Red Flags and Emergency Presentations

Certain BPSD presentations require urgent assessment and intervention:

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5. Clinical Examination

Structured Assessment of BPSD

A comprehensive examination of a patient with BPSD includes:

1. General Observation

• Appearance: Unkempt, disheveled (neglect of personal hygiene may indicate apathy or depression)
• Behavior: Agitation, pacing, restlessness, verbal outbursts, withdrawal
• Affect: Flat (apathy), tearful (depression), anxious, labile (vascular dementia, frontotemporal dementia)

2. Mental State Examination

3. Physical Examination to Exclude Medical Causes

Key focus: Identify pain, infection, and constipation—the most common reversible triggers. [3,4]

Clinical Pearl: "The Pain Assessment Paradox": Patients with advanced dementia cannot self-report pain reliably. Use observational pain scales (Abbey Pain Scale, PAINAD) that assess facial expression, vocalizations, body language, and response to movement. [4] A trial of regular analgesia is both diagnostic and therapeutic.

4. Medication Review

Review all medications for drugs that can precipitate or worsen BPSD:

5. Environmental Assessment

• Noise levels: Excessive noise or overstimulation?
• Lighting: Adequate lighting to prevent misperceptions?
• Familiarity: Is the environment new or unfamiliar?
• Routine: Has there been a change in routine or caregivers?
• Social interaction: Is the patient isolated, bored, or lacking meaningful activity?

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6. Investigations

Exclude Reversible Medical Causes

The primary goal of investigations in BPSD is to identify and treat reversible medical precipitants. [3,4]

Clinical Pearl: "Urine Dip First": In any dementia patient with acute behavioral change, perform a urinalysis as a first-line investigation. [3] Asymptomatic bacteriuria is common in the elderly and should not be treated, but symptomatic UTI (confusion, dysuria, fever, behavioral change) requires antibiotics.

BPSD-Specific Assessment Tools

Standardized tools quantify BPSD severity and monitor treatment response: [11]

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7. Management

Overview: The DICE Approach

The DICE framework (Describe, Investigate, Create, Evaluate) provides a structured, person-centered approach to BPSD management. [10]

Stepwise Management Algorithm

┌─────────────────────────────────────────────────────────────────┐
│                    BPSD MANAGEMENT ALGORITHM                    │
├─────────────────────────────────────────────────────────────────┤
│                                                                 │
│  STEP 1: IDENTIFY AND TREAT REVERSIBLE CAUSES                   │
│  ───────────────────────────────────────────────────────────    │
│  • Pain (musculoskeletal, neuropathic, visceral, dental)        │
│    → Trial of regular paracetamol 1g QDS [4]                    │
│  • Infection (UTI, pneumonia, cellulitis, wounds)               │
│    → Urinalysis, FBC, CRP, CXR; antibiotics if indicated [3]    │
│  • Constipation / Fecal impaction                               │
│    → Abdominal exam, AXR; laxatives, suppositories [3]          │
│  • Urinary retention                                            │
│    → Bladder scan; catheterization if needed                    │
│  • Medication review                                            │
│    → Stop anticholinergics, benzodiazepines, opioids [3]        │
│  • Delirium (acute confusion superimposed on dementia)          │
│    → Treat underlying cause; supportive care [3]                │
│  • Metabolic disturbances (hyponatremia, hypoglycemia, etc.)    │
│    → U&E, glucose, calcium, TFT; correct abnormalities          │
│                                                                 │
│  STEP 2: NON-PHARMACOLOGICAL INTERVENTIONS (FIRST-LINE) [5,6]    │
│  ─────────────────────────────────────────────────────────────  │
│  • Person-centered care (individualized, respectful approach)   │
│  • Address unmet needs (hunger, thirst, toileting, pain,        │
│    boredom, loneliness)                                         │
│  • Environmental modifications:                                 │
│    - Reduce noise, overstimulation                              │
│    - Increase lighting (prevent misperceptions)                 │
│    - Familiar objects, photographs                              │
│    - Consistent routine                                         │
│  • Structured, meaningful activities (music, art, reminiscence) │
│  • Music therapy [5,6]                                          │
│  • Aromatherapy (lavender, melissa) [6]                         │
│  • Multisensory stimulation (Snoezelen)                         │
│  • Pet therapy                                                  │
│  • Exercise programs (reduce agitation, improve sleep)          │
│  • Caregiver education and support (reduce caregiver burden) [9]│
│                                                                 │
│  STEP 3: OPTIMIZE DEMENTIA-SPECIFIC MEDICATIONS [12]             │
│  ─────────────────────────────────────────────────────────────  │
│  • Acetylcholinesterase inhibitors (Donepezil, Rivastigmine,   │
│    Galantamine) may reduce BPSD in Alzheimer's disease [12]    │
│  • Memantine may reduce agitation in moderate-to-severe         │
│    Alzheimer's disease [12]                                     │
│                                                                 │
│  STEP 4: PHARMACOLOGICAL MANAGEMENT (LAST RESORT) [7,8]          │
│  ─────────────────────────────────────────────────────────────  │
│  ** Only if severe symptoms with risk to patient or others **   │
│  ** After failure of non-pharmacological interventions **       │
│  ** Informed consent discussion with patient/family re: risks **│
│                                                                 │
│  A. FOR AGITATION/AGGRESSION/PSYCHOSIS:                         │
│                                                                 │
│     Antipsychotics (⚠️ BLACK BOX WARNING) [7,8]                 │
│     ─────────────────────────────────────────────────────────   │
│     • Risperidone 0.25-1mg BD (licensed for BPSD in UK)         │
│       - Start 0.25mg BD, increase gradually                     │
│       - Max 1mg BD; use for ≤6 weeks if possible                │
│       - ⚠️ Increased stroke risk (NNH ~53-100)                  │
│       - ⚠️ Increased mortality (1.6-1.7x) [7,8]                 │
│       - Monitor for parkinsonism, sedation, falls               │
│                                                                 │
│     • Quetiapine 12.5-50mg BD (unlicensed)                      │
│       - Lower risk of extrapyramidal side effects               │
│       - Preferred if Lewy body dementia (but still caution) [13]│
│                                                                 │
│     • Olanzapine 2.5-5mg OD (unlicensed)                        │
│       - Risk of stroke, sedation, metabolic syndrome            │
│                                                                 │
│     ⚠️ AVOID: Haloperidol (high risk of parkinsonism, falls)    │
│     ⚠️ CONTRAINDICATED in Lewy body dementia (severe neuroleptic│
│        sensitivity) [13]                                        │
│                                                                 │
│  B. FOR DEPRESSION/ANXIETY:                                     │
│                                                                 │
│     • Sertraline 25-100mg OD (SSRI)                             │
│       - First-line; good evidence for depression in dementia    │
│       - Start low, increase slowly                              │
│                                                                 │
│     • Citalopram 10-20mg OD                                     │
│       - ⚠️ Risk of QTc prolongation at higher doses             │
│       - Max 20mg in elderly; avoid if cardiac disease           │
│                                                                 │
│     • Mirtazapine 15-30mg nocte                                 │
│       - Useful if insomnia or poor appetite                     │
│       - Sedating (helpful for sleep)                            │
│                                                                 │
│     • Trazodone 25-100mg nocte                                  │
│       - Sedating; useful for agitation + insomnia               │
│                                                                 │
│  C. FOR SLEEP DISTURBANCE:                                      │
│                                                                 │
│     • Melatonin 2-6mg nocte (first-line)                        │
│       - Improves sleep, minimal side effects                    │
│                                                                 │
│     • Trazodone 25-100mg nocte                                  │
│       - If melatonin ineffective                                │
│                                                                 │
│     ⚠️ AVOID: Benzodiazepines (worsen confusion, falls, paradoxical│
│        agitation)                                               │
│     ⚠️ AVOID: Z-drugs (zopiclone, zolpidem) – similar risks     │
│                                                                 │
│  D. FOR SEVERE ACUTE AGITATION (EMERGENCY):                     │
│                                                                 │
│     • Lorazepam 0.5-1mg PO/IM/IV PRN                            │
│       - Short-term use only (risk of falls, confusion)          │
│       - Reassess frequently; taper as soon as possible          │
│                                                                 │
│  STEP 5: REGULAR REVIEW AND DE-PRESCRIPTION                     │
│  ─────────────────────────────────────────────────────────────  │
│  • Review antipsychotics every 1-2 weeks initially              │
│  • Attempt dose reduction or discontinuation at 6-12 weeks [7,8]│
│  • Monitor for symptom recurrence                               │
│  • Document reasons for continuation if > 12 weeks               │
│                                                                 │
└─────────────────────────────────────────────────────────────────┘

Exam Detail: ### Evidence Base for Pharmacological Interventions

Antipsychotics

Risperidone: The CATIE-AD and DART-AD trials demonstrated modest efficacy for agitation and aggression but increased mortality (HR 1.6-1.7) and stroke risk (OR 3.0). [7,8,15] The number needed to harm for stroke is approximately 53-100 patients. [7] Risperidone is the only antipsychotic licensed for BPSD in the UK (for up to 6 weeks). [7]

Quetiapine: Evidence is weaker than for risperidone, but it has a lower risk of extrapyramidal side effects, making it preferable in patients at risk of parkinsonism (e.g., Lewy body dementia, Parkinson's disease dementia). [8,16] However, it still carries stroke and mortality risks. [16]

Haloperidol: Older trials showed efficacy for agitation, but high risk of parkinsonism, sedation, and falls. [7] Generally avoided in favor of atypical antipsychotics.

Olanzapine: Similar efficacy to risperidone but associated with metabolic syndrome, sedation, and stroke. [7]

Acetylcholinesterase Inhibitors

Donepezil, rivastigmine, and galantamine may reduce BPSD (particularly apathy and hallucinations) in Alzheimer's disease. [12] A Cochrane review found modest benefits for neuropsychiatric symptoms. [12] These agents should be optimized before considering antipsychotics.

Memantine

Memantine may reduce agitation in moderate-to-severe Alzheimer's disease. [12] It is generally well-tolerated and does not carry the risks associated with antipsychotics. [12]

Antidepressants

SSRIs (sertraline, citalopram) are moderately effective for depression and anxiety in dementia. [17] Sertraline is first-line due to favorable side effect profile. [17] Citalopram has been shown to reduce agitation in some studies, but concerns about QTc prolongation limit its use (max 20mg in elderly). [17]

Benzodiazepines

Generally avoided due to risks of falls, confusion, paradoxical agitation, and dependence. [7] Short-term use of lorazepam 0.5-1mg may be necessary for severe acute agitation, but only as a bridge to other interventions. [7]

Clinical Pearl: ### Special Considerations in Lewy Body Dementia

Patients with Lewy body dementia exhibit severe neuroleptic sensitivity, with reactions including:

• Acute worsening of parkinsonism (rigidity, bradykinesia, tremor)
• Severe sedation
• Confusion
• Increased mortality [13]

Management principles:

• Avoid typical antipsychotics entirely (haloperidol, chlorpromazine) [13]
• If antipsychotic absolutely necessary (severe psychosis with risk), use quetiapine 12.5-25mg with extreme caution [13]
• Consider acetylcholinesterase inhibitors (rivastigmine) as first-line for hallucinations and delusions [13]
• Involve specialist (old age psychiatry or neurology) [13]

Non-Pharmacological Interventions: Evidence Base

A Cochrane systematic review of non-pharmacological interventions found moderate evidence for: [5,6]

Practical Application: Non-pharmacological interventions should be individualized based on the patient's preferences, interests, and abilities. [5,6] For example:

• A patient who enjoyed gardening: horticultural therapy
• A patient who loved music: personalized music playlists
• A patient who was socially active: group activities, pet therapy

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8. Complications

Complications of BPSD

Complications of Pharmacological Treatment

Clinical Pearl: "The De-Prescribing Imperative": Once initiated, antipsychotics should be reviewed every 1-2 weeks initially, with attempted dose reduction or discontinuation at 6-12 weeks. [7,8] Studies show that many patients can successfully discontinue antipsychotics without symptom recurrence. [18] Document reasons for continuation if used beyond 12 weeks. [7,8]

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9. Prognosis and Outcomes

Natural History of BPSD

• BPSD symptoms fluctuate over the course of dementia; some symptoms (e.g., depression, delusions) may improve spontaneously over time, while others (e.g., apathy) tend to worsen with disease progression. [2]
• Apathy is the most persistent symptom, increasing in prevalence as dementia severity worsens. [2]
• Agitation and aggression peak in moderate-to-severe dementia and may decrease in very advanced dementia (patient becomes less mobile and more withdrawn). [2]
• Psychotic symptoms (delusions, hallucinations) are more common in moderate dementia and may decrease as cognition declines further. [2]

Prognostic Factors

Impact on Caregivers

BPSD is the single most important predictor of caregiver burden, surpassing cognitive impairment. [9] Consequences include:

• Caregiver depression and anxiety [9]
• Physical exhaustion (sleep deprivation from nocturnal wandering) [9]
• Social isolation (inability to leave patient alone) [9]
• Financial strain (need for paid caregivers, loss of work) [9]
• Institutionalization (caregiver burnout is the primary driver of nursing home placement) [9]

Intervention: Caregiver education, respite care, support groups, and psychological therapies reduce caregiver burden and delay institutionalization. [9,19]

Mortality

• BPSD is associated with increased mortality, independent of dementia severity. [9]
• Antipsychotic use in dementia increases mortality risk by 1.6-1.7 times. [7,8]
• Severe agitation and aggression are associated with faster functional decline and higher mortality. [9]

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10. Prevention and Early Intervention

Primary Prevention

There are no established primary prevention strategies for BPSD, as it is a consequence of neurodegenerative disease. However, dementia prevention strategies (cardiovascular risk reduction, physical activity, cognitive stimulation, social engagement) may reduce overall dementia burden and, consequently, BPSD. [20]

Secondary Prevention (Preventing BPSD in Established Dementia)

Tertiary Prevention (Preventing Complications of BPSD)

• Falls prevention: Risk assessment, physiotherapy, environmental modifications, avoid sedatives
• Nutritional support: Regular weighing, nutritional supplements, assistance with eating
• Skin care: Pressure area care, repositioning, adequate nutrition and hydration
• Caregiver support: Respite care, support groups, psychological therapies [9,19]

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11. Evidence and Guidelines

Key Guidelines

Landmark Trials

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12. Examination Focus

Viva Questions and Model Answers

Exam Detail: Q1: A 78-year-old man with Alzheimer's disease is brought to A&E by his family due to increasing agitation and aggression over the past 3 days. He has been shouting, hitting caregivers, and refusing personal care. What is your approach?

Model Answer:

This is a case of acute behavioral change in a patient with established dementia, which should be approached as delirium superimposed on dementia until proven otherwise. [3]

Step 1: Immediate assessment

• Ensure safety (patient, staff, family)
• Brief history from family: timeline of behavior change, baseline dementia, recent illnesses, medications, pain

Step 2: Identify and treat reversible causes [3,4]

• Pain: Facial grimacing? Guarding? Trial of paracetamol 1g QDS [4]
• Infection: Urinalysis (UTI most common), FBC, CRP, CXR (pneumonia), examine for cellulitis, wounds [3]
• Constipation: Abdominal exam, AXR if indicated; laxatives [3]
• Urinary retention: Bladder scan; catheterization if needed
• Medication review: Recent additions? Anticholinergics? Benzodiazepines? Opioids? [3]
• Metabolic: U&E (hyponatremia, uremia), glucose, calcium, TFT

Step 3: Non-pharmacological management [5,6]

• Calm, quiet environment
• Familiar caregiver
• Reassurance
• Address unmet needs (hunger, thirst, toileting, pain)

Step 4: Pharmacological management (if necessary) [7,8]

• If severe agitation with risk: Lorazepam 0.5-1mg PO/IM (short-term only)
• Once reversible causes treated, if persistent severe BPSD: consider risperidone 0.25mg BD (discuss risks with family: stroke, mortality) [7,8]

Step 5: Ongoing management

• Monitor for response and side effects
• Involve MDT (OT, physiotherapy, psychiatry)
• Caregiver support and education [9]

Key Principle: Delirium until proven otherwise—focus on identifying and treating medical precipitants. [3]

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Q2: What are the risks of antipsychotic use in dementia, and when would you prescribe them?

Model Answer:

Risks of antipsychotics in dementia [7,8]:

1. Increased mortality (HR 1.6-1.7; approximately 1-2% absolute increase in death over 6-12 weeks) [7,8]
2. Increased stroke risk (OR 3.0; NNH ~53-100) [7,8]
3. Parkinsonism (rigidity, bradykinesia, tremor)
4. Sedation and falls
5. QTc prolongation (citalopram, haloperidol)
6. Severe neuroleptic sensitivity in Lewy body dementia (contraindicated) [13]

Black box warning from FDA and MHRA. [7,8]

When to prescribe:

• Only after exhausting non-pharmacological interventions [7,8]
• Only if severe symptoms with risk to patient or others (e.g., severe aggression, psychosis causing distress) [7,8]
• Informed consent discussion with patient (if capacity) and family regarding risks [7,8]
• Lowest effective dose for shortest duration (ideally ≤6 weeks) [7,8]

Choice of antipsychotic:

• Risperidone 0.25-1mg BD (only licensed antipsychotic for BPSD in UK) [7]
• Quetiapine 12.5-50mg BD if parkinsonism risk or Lewy body dementia (but still caution) [13,16]

Monitoring:

• Review every 1-2 weeks initially
• Attempt dose reduction or withdrawal at 6-12 weeks [7,8]
• Document reasons for continuation if > 12 weeks

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Q3: How does BPSD differ between Alzheimer's disease and Lewy body dementia?

Model Answer:

Key Difference for Exams: Visual hallucinations are a core diagnostic feature of Lewy body dementia and occur early, whereas in Alzheimer's they are late and less common. [13] Neuroleptic sensitivity in Lewy body dementia is a critical safety issue. [13]

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Q4: Describe the DICE approach to managing BPSD.

Model Answer:

DICE is a structured, person-centered framework for managing BPSD. [10]

Key Principles: [10]

• Person-centered: Tailored to individual patient's needs, preferences, and life history
• Multidisciplinary: Involve nursing, OT, physiotherapy, family
• Non-pharmacological first: Medication is last resort [5,6]
• Iterative: Continuously evaluate and adapt

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Q5: What non-pharmacological interventions have evidence for managing BPSD?

Model Answer:

A Cochrane systematic review found moderate evidence for: [5,6]

Practical Application: Interventions should be individualized based on patient's life history, preferences, and abilities. [5,6] For example:

• Patient who loved gardening: horticultural therapy
• Patient who was a musician: personalized music
• Patient who was socially active: group activities, pet therapy

Key Principle: Non-pharmacological interventions are first-line for BPSD and should be exhausted before considering pharmacological options. [5,6]

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13. Patient and Layperson Explanation

What is BPSD?

BPSD stands for "Behavioural and Psychological Symptoms of Dementia." It includes a wide range of symptoms such as:

• Behavioral symptoms: Agitation, restlessness, wandering, aggression, shouting, sleep problems
• Psychological symptoms: Depression, anxiety, hallucinations (seeing or hearing things that aren't there), delusions (believing things that aren't true, like "someone is stealing from me")

Almost everyone with dementia will experience some of these symptoms at some point. [1,2]

Why Does It Happen?

People with dementia often cannot communicate their needs clearly. Behavioral changes are usually a sign that something is wrong—they might be in pain, have an infection (like a urine or chest infection), be constipated, feel scared or bored, or be in an unfamiliar place. [3,4]

The brain changes caused by dementia can also lead to these symptoms, especially as the disease progresses.

How is BPSD Managed?

Step 1: Find and Treat Medical Causes [3,4]

• Check for pain (arthritis, injuries)
• Check for infections (urine infection, chest infection)
• Check for constipation
• Review medications (some drugs can cause confusion or agitation)

Step 2: Non-Drug Approaches (First-Line) [5,6]

• Create a calm, familiar environment
• Use music the person enjoys
• Provide meaningful activities (art, gardening, reminiscence)
• Stick to a regular routine
• Make sure the person is not hungry, thirsty, or needs the toilet
• Reassure and comfort the person

Step 3: Medications (Last Resort) [7,8]

• If symptoms are severe and other approaches haven't worked, doctors may prescribe medications such as antipsychotics (e.g., risperidone) or antidepressants (e.g., sertraline)
• Important: Antipsychotics carry risks in older people with dementia, including increased risk of stroke and death. [7,8] They should only be used for short periods (ideally 6 weeks or less) and at the lowest possible dose. [7,8]

What Should Caregivers Do?

• Stay calm and reassuring—your loved one is not being difficult on purpose; they are distressed
• Try to understand what they need—are they in pain? Bored? Frightened?
• Create a calm, quiet environment
• Use familiar objects and routines
• Report sudden changes in behavior to your GP immediately (this could be a sign of infection or other medical problem) [3]
• Look after yourself—caregiver burnout is common. Use respite care, support groups, and ask for help. [9,19]

When to Seek Help

• Sudden change in behavior (could be an infection or other medical problem) [3]
• Severe aggression (risk to the person or others)
• Refusal to eat or drink for more than 24-48 hours
• Signs of depression or suicidal thoughts

Remember: BPSD is distressing, but it can often be improved with the right approach. Medical causes should always be checked first, and non-drug approaches should be tried before medications. [3,4,5,6]

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14. References

1. Guideline Recommendations on Behavioral and Psychological Symptoms of Dementia: A systematic review of current evidence. PMID: 38640961

2. Management of Behavioral and Psychological Symptoms of Dementia. PMID: 31264056

3. Behavioral and psychological symptoms in Alzheimer's dementia and vascular dementia. PMID: 31727229

4. Association between pain and behavioral and psychological symptoms of dementia (BPSD). PMID: 39953384

5. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older adults with dementia. PMID: 28302633

6. Exploration of non-pharmacological interventions in the management of behavioural and psychological symptoms of dementia. PMID: 34600449

7. A randomised, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics (DART-AD trial). PLoS Med. 2008. PMID: 18384229

8. A European Academy of Neurology guideline on medical management issues in dementia. PMID: 32713125

9. Managing Behavioral and Psychological Symptoms of Dementia (BPSD) in the Era of Person-Centered Care. PMID: 35781675

10. DICE approach: Describe, Investigate, Create, Evaluate framework for BPSD management. Expert consensus and clinical guidelines

11. Neuropsychiatric Inventory (NPI) and Cohen-Mansfield Agitation Inventory (CMAI) for BPSD assessment. Clinical assessment tools

12. An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia. PMID: 29143695

13. Lewy body dementia hallucinations and antipsychotic sensitivity. Clinical neurology and neuropsychiatry literature

14. Behavioral and psychological symptoms of dementia: neurobiological mechanisms. PMID: 22586419

15. CATIE-AD Trial: Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. N Engl J Med. 2006. PMID: 17035647

16. Safety of Low-Dose Quetiapine for Insomnia in Older Adults. PMID: 39747780

17. Citalopram for agitation in Alzheimer disease: the CitAD randomized clinical trial (CALM-AD). JAMA. 2014. PMID: 24862458

18. Health Outcomes of Discontinuing Antipsychotics After Hospitalization in Older Adults With Dementia. PMID: 40366701

19. Caregiver education and support interventions for dementia: systematic reviews and meta-analyses. Multiple studies; see NICE NG97

20. American Psychiatric Association Practice Guideline for the Treatment of Patients with Alzheimer's Disease and Other Dementias. Am J Psychiatry. 2014.

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Additional Key Studies:

• Sequential drug treatment algorithm for agitation and aggression in Alzheimer's and mixed dementia. PMID: 29338602

• Clinical Practice Guidelines for Dementia: Recommendations for the Pharmacological Management of Neuropsychiatric Symptoms. PMID: 39944528

• Clinical Perception and Treatment Options for Behavioral and Psychological Symptoms of Dementia. PMID: 35432010

• Gabapentin and pregabalin to treat aggressivity in dementia: a systematic review and appraisal. PMID: 30575088

• Population-based 5-year follow-up study in Taiwan of dementia and risk of stroke. PMID: 23626726

• Underlying disease may increase mortality risk in users of atypical antipsychotics versus typical antipsychotics: a propensity-score matched nationwide population-based study. PMID: 36158300

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Further Reading:

• NICE NG97: Dementia: Assessment, Management and Support for People Living with Dementia and Their Carers. 2018. nice.org.uk/guidance/ng97

• Maudsley Prescribing Guidelines in Psychiatry (13th Edition): Dementia chapter

• IPA (International Psychogeriatric Association) Complete Guide to BPSD

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