Psych · Old age psychiatry — dementia neuropsychiatry
Behavioural and psychological symptoms of dementia
Also known as BPSD · Neuropsychiatric symptoms of dementia · NPS dementia · Dementia-related behavioural disturbance · Agitation in dementia · Psychosis of Alzheimer disease · Behavioural symptoms of dementia
Exam-exhaustive fellowship reference on behavioural and psychological symptoms of dementia (BPSD/NPS) — domains and NPI framing; multifactorial drivers including pain; DICE assessment; non-drug first-line care; antipsychotic mortality and stroke risk; CATIE-AD, DART-AD, CitAD, HTA-SADD; deprescribing; carer support. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Acute behavioural change with fluctuating attention — treat as delirium until proven otherwise; hunt infection, drugs, metabolic causes
- Severe aggression with risk of harm to self/others — safety first, medical exclusion, least-restrictive legal status; do not default to high-dose IM antipsychotic
- Suspected dementia with Lewy bodies and new psychosis/agitation — avoid typical antipsychotics; extreme caution with atypicals (neuroleptic sensitivity)
- Antipsychotic started without documented target symptom, non-drug trial, or review date — high mortality and stroke risk; plan deprescribing
- Pain, constipation, urinary retention, or pressure injury unrecognised as drivers of calling-out or aggression
- Carer crisis, elder abuse, or unsafe discharge plan — escalate social supports and safeguarding
Meet the patient
A 79-year-old woman with moderate Alzheimer disease has lived in residential care for a year. For three weeks she has told every visitor that the staff are stealing her rings. Last night she struck a care worker during the evening change.[2][5]
Ten weeks ago she fractured her wrist. It is "healed". She has not opened her bowels for four days, her hearing aid battery died in March, and the evening shift is two staff short. The facility has faxed a request for regular risperidone.[5][12]
Two exam questions are live, and they are the whole topic. What is she actually telling you? And what will you have to say to her daughter if you sign that script? Everything below answers both.[5][6]
References22ShowHide
- [1]Finkel SI, Costa e Silva J, Cohen G, Miller S, Sartorius N Behavioral and psychological signs and symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment Int Psychogeriatr, 1996.PMID 9154615
- [2]Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia Neurology, 1994.PMID 7991117
- [3]Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study JAMA, 2002.PMID 12243634
- [4]Steinberg M, Shao H, Zandi P, Lyketsos CG, Welsh-Bohmer KA, Norton MC, et al. Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study Int J Geriatr Psychiatry, 2008.PMID 17607801
- [5]Kales HC, Gitlin LN, Lyketsos CG Assessment and management of behavioral and psychological symptoms of dementia BMJ, 2015.PMID 25731881
- [6]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
- [7]Schneider LS, Tariot PN, Dagerman KS, Davis SM, Hsiao JK, Ismail MS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease N Engl J Med, 2006.PMID 17035647
- [8]Sultzer DL, Davis SM, Tariot PN, Dagerman KS, Lebowitz BD, Lyketsos CG, et al. Clinical symptom responses to atypical antipsychotic medications in Alzheimer's disease: phase 1 outcomes from the CATIE-AD effectiveness trial Am J Psychiatry, 2008.PMID 18519523
- [9]Ballard C, Lana MM, Theodoulou M, Douglas S, McShane R, Jacoby R, et al. A randomised, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics (the DART-AD trial) PLoS Med, 2008.PMID 18384230
- [10]Ballard C, Hanney ML, Theodoulou M, Douglas S, McShane R, Kossakowski K, et al. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial Lancet Neurol, 2009.PMID 19138567
- [11]Devanand DP, Mintzer J, Schultz SK, Andrews HF, Sultzer DL, de la Pena D, et al. Relapse risk after discontinuation of risperidone in Alzheimer's disease N Engl J Med, 2012.PMID 23075176
- [12]Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial BMJ, 2011.PMID 21765198
- [13]Livingston G, Kelly L, Lewis-Holmes E, Baio G, Morris S, Patel N, et al. Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials Br J Psychiatry, 2014.PMID 25452601
- [14]Brodaty H, Arasaratnam C Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia Am J Psychiatry, 2012.PMID 22952073
- [15]Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, et al. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial JAMA, 2014.PMID 24549548
- [16]Banerjee S, Hellier J, Dewey M, Romeo R, Ballard C, Baldwin R, et al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial Lancet, 2011.PMID 21764118
- [17]Maher AR, Maglione M, Bagley S, Suttorp M, Hu JH, Ewing B, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis JAMA, 2011.PMID 21954480
- [18]Ballard C, Waite J The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer's disease Cochrane Database Syst Rev, 2006.PMID 16437455
- [19]Gill SS, Bronskill SE, Normand SL, Anderson GM, Sykora K, Lam K, et al. Antipsychotic drug use and mortality in older adults with dementia Ann Intern Med, 2007.PMID 17548409
- [20]Wooltorton E Risperidone (Risperdal): increased rate of cerebrovascular events in dementia trials CMAJ, 2002.PMID 12451085
- [21]Fox C, Crugel M, Maidment I, Auestad BH, Coulton S, Treloar A, et al. Efficacy of memantine for agitation in Alzheimer's dementia: a randomised double-blind placebo controlled trial PLoS One, 2012.PMID 22567095
- [22]Lee D, Slomkowski M, Hefting N, Chen D, Larsen KG, Kohegyi E, et al. Brexpiprazole for the Treatment of Agitation in Alzheimer Dementia: A Randomized Clinical Trial JAMA Neurol, 2023.PMID 37930669