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Dementia: Managing challenging behaviours

Behavioural and psychological symptoms of dementia

In addition to the cognitive changes of dementia, it is also common for people to develop behavioural and psychological symptoms of dementia (BPSD).

BPSD is common, affecting 40 to 80 per cent of people with dementia. It is associated with increased caregiver burden and increased likelihood of being placed in a nursing home.

BPSD can emerge at any stage of dementia. It includes behaviours such as:

  • agitation and restlessness
  • anxiety
  • apathy/failure to participate, withdrawing, crying
  • defensiveness
  • hearing and seeing things that are not there
  • hoarding and rummaging
  • impulsivity
  • inappropriate sexual behaviour
  • intrusiveness
  • resistance to care
  • suspiciousness, accusing others
  • vocally disruptive behaviour
  • wandering

Steps in evaluating and treating BPSD

Obtain a clear description of the behaviour using the ABC approach:

  • What are the Antecedents to the behaviour?
  • What exactly is the Behaviour? (Be more specific than "agitated" or "aggressive.")
  • What is the Consequence (caregiver's response) of the behaviour?

Rule out other causes of the behaviour

After obtaining a clear description, the next step is to rule out potential reversible secondary causes of the behaviour. Evaluate delirium risk using the three-question template  (What has changed? What are the risks and causes? What is the action?) to enable a systematic and comprehensive approach.

Delirium can present with behavioural disturbances in older adults with dementia and should first be ruled out (see the algorithm for diagnosing delirium). Also, potential medical conditions that may exacerbate behaviours include pain, unmet needs, constipation and environmental contributors.

Initiate non-pharmacological management

Initiate non-pharmacological management for the specific behaviours. Educate caregivers, which can decrease distress and negative responses to behaviours. Pharmacological treatments may need to be considered early if the behaviours are endangering others or cause extreme distress.

Determine impact and risks of the behaviour

To determine the impact of the behaviour and the risks associated with it, and to monitor response, use the four Ds approach:

Is the behaviour:

  • Dangerous?
  • Distressing?
  • Disturbing relationships or jeopardizing independence due to the effects on the caregivers? and/or
  • causing Disability (e.g., medical malnutrition, risk for falls)?

Optimize treatment using pharmacotherapy

If the behaviour persists, consider optimizing the treatment of the underlying dementia. This may include taking measures to prevent further cognitive decline and prescribing cognitive enhancers.

Evaluate and treat possible co-existing depression or anxiety using appropriate pharmacotherapy (e.g., SSRIs) and psychosocial interventions.

If these interventions fail, consider pharmacotherapy directed at the BPSD. Consider referral to psychiatry, neurology or geriatric medicine.

Medications for treating BPSD

In addition to treating the underlying dementia with appropriate psychosocial and pharmacological treatment, several medications have demonstrated efficacy in treating certain BPSD behaviours. Table 10.3: Medications for treatment of psychological symptoms of dementia summarizes information about indications, dose, side-effects and monitoring.

Behaviours that generally are not amenable to pharmacotherapy include wandering, repetitive questioning or vocalizing, abnormal eating behaviours, perseverative behaviours, inappropriate dressing or undressing and inappropriate defecation or urination.

Behaviours that may respond to pharmacotherapy include:

  • verbal aggression
  • anxiety
  • agitation
  • sadness
  • insomnia
  • sleep disturbances
  • hyperactivity
  • persistent delusions or hallucinations
  • sexually inappropriate behaviour accompanied by agitation

Atypical antipsychotics

Atypical antipsychotics are the best supported treatment for severe agitation or psychosis in dementia that is unresponsive to non-pharmacological interventions.

The potential benefits of these medications must be balanced with potential serious adverse effects. Atypical antipsychotics have been associated with increased risk of death and stroke when used to treat BPSD. Patients need to be warned of the potential risks and monitored carefully for adverse events.

Other medications

Other medications with some evidence for use in BPSD include SSRIs, such as citalopram and the antidepressant trazodone. There is little or no evidence to support the use of benzodiazepines or other hypnotics, and because there are significant safety concerns associated with them, they are not recommended.

Psychiatry in primary care toolkit

The Psychiatry in Primary Care App has been decommissioned. 

The revised print version of Psychiatry in Primary Care is avaible through the CAMH store. 

We have posted a number of revised chapters from the book in Treating Conditions and Disorders in the new Professionals section of