Behavioural and Psychological (BPSD) Symptoms of Dementia

🧠 Introduction

• 👉 Behavioural and Psychological Symptoms of Dementia (BPSD) develop in more than 90% of individuals with dementia.
• Symptoms include: delusions, hallucinations, aggression, screaming, restlessness, wandering, depression, and anxiety.
• Other features: disinhibition, sexual behaviours, apathy, sleep disturbance, and compulsive/repetitive behaviours.
• ⚠️ BPSD is associated with poorer quality of life, higher care costs, rapid cognitive decline, and significant caregiver burden.

📊 Prevalence

• 👥 Community: ~60% of dementia patients show BPSD.
• 🏥 Nursing homes: ~80% prevalence.
• 📅 Over 5 years, >90% of dementia patients will develop BPSD.

🩺 Differential Causes Mimicking BPSD

• 🌀 Acute delirium (hypoactive or hyperactive) or severe depression.
• 🤕 Pain: look for non-verbal cues (e.g. grimacing, limb avoidance, dental or catheter pain).
• 🦠 Infections: UTI, chest infection, or constipation. 🔬 Electrolyte disturbances e.g. hyponatraemia.
• 🏠 Environmental factors: overstimulation, poor lighting, untrained staff.
• 💊 Medications: anticholinergics, opioids, benzodiazepines, antipsychotics, anticonvulsants, antihistamines, corticosteroids, TCAs, digoxin, anti-Parkinsonian drugs.

❓ What is BPSD?

• A cluster of non-cognitive symptoms in dementia involving perception, mood, thought, or behaviour.
• Psychological symptoms: hallucinations, delusions, anxiety, agitation.
• Behavioural symptoms: aggression, wandering, hoarding, disinhibition, apathy, shouting/vocalisation.
• 🗝️ Often reflects unmet needs (pain, hunger, toileting, boredom, overstimulation).

💊 Management Strategy

• 🔎 First, exclude delirium, infection, pain, or drug side effects. Minimum screen: U&Es, FBC, CRP, B12, folate, TFTs, MSU.
• 🌱 Non-pharmacological approaches (first-line):
  • Calm, consistent, well-lit environment with trained staff.
  • Reduce overstimulation/noise, ensure hydration, nutrition, and toileting needs are met.
  • Encourage structured activities, reassurance, and person-centred care.
• 💊 Pharmacological options (if severe / risk to self or others):
  • Antipsychotics: Risperidone (up to 1 mg BD, max 6 weeks). ⚠️ Stroke risk. Consider olanzapine or aripiprazole if risperidone unsuitable (not licensed for BPSD).
  • SSRIs: Citalopram, sertraline, or mirtazapine for co-existing depression/anxiety.
  • Paracetamol trial: Regular dosing for 1 week, even without overt pain (to address occult discomfort).
  • For acute severe agitation: short-term haloperidol (0.5–4 mg) or lorazepam (avoid IV).
• 🔄 Treatment review every 3 months (or sooner). Do not continue antipsychotics >6 weeks without reassessment.

⚠️ Key Clinical Pearls

• 🧩 BPSD is often a manifestation of unmet needs rather than “bad behaviour.”
• 🚫 Avoid long-term antipsychotics unless absolutely necessary.
• 💡 Multidisciplinary input (GP, psychiatry, geriatrician, nurses, carers) improves outcomes.
• 👨‍👩‍👧 Carer support and education are as vital as direct treatment of the patient.

📚 References

• Lancashire Guidance: Management of BPSD
• NICE Dementia Guideline NG97

Clinical cases

• 🧓 Case 1 – Age 82: Woman with Alzheimer’s disease became increasingly agitated in the evenings, accusing carers of theft and refusing care. No new medical issues on review. Diagnosis: Behavioural and psychological symptoms of dementia (BPSD) - agitation and paranoid delusions. Management: Non-pharmacological strategies first: reassurance, calm environment, and carer education. Low-dose risperidone considered for short-term control. Teaching point: Always exclude pain, infection, or medication side-effects before attributing agitation to BPSD - antipsychotics carry cerebrovascular and mortality risks in dementia.
• 🛏️ Case 2 – Age 78: Man with vascular dementia began wandering at night, attempting to leave the house believing he needed to “go to work.” Carers reported exhaustion and safety concerns. Diagnosis: BPSD with disorientation and wandering behaviour. Management: Establish structured daytime activity, improve lighting to reduce “sundowning,” and install motion alarms. Teaching point: Wandering often reflects unmet needs or circadian disruption - behavioural and environmental adjustments are more effective than sedation.
• 🎶 Case 3 – Age 85: Woman in a care home with Lewy body dementia became withdrawn and depressed, with visual hallucinations of children in her room. Diagnosis: BPSD presenting as hallucinations and depression in Lewy body dementia. Management: SSRIs for mood; cholinesterase inhibitor (e.g. rivastigmine) for cognitive and behavioural symptoms. Avoid typical antipsychotics due to severe sensitivity. Teaching point: The phenotype of BPSD varies by dementia type - visual hallucinations and mood change are typical of Lewy body disease, not Alzheimer’s.