Behavioral and Psychological Symptoms of Dementia (BPSD) is a collective term for the non-cognitive changes that occur frequently in individuals living with a major neurocognitive disorder. These symptoms often include emotional distress, altered perception, and disruptive actions. The majority of people with dementia, sometimes over 90%, will experience at least one type of BPSD as the disease progresses. BPSD is highly distressing for the person affected and their caregivers, and it is a primary factor leading to institutionalization. Effective management requires understanding the underlying causes and applying person-centered strategies before considering medical treatment.
The Spectrum of Behavioral and Psychological Symptoms
The manifestations of BPSD are wide-ranging, reflecting damage to various parts of the brain responsible for emotion, behavior, and perception. These symptoms can be grouped into several categories.
One major grouping includes psychotic symptoms, such as delusions and hallucinations. Delusions are false, fixed beliefs, often paranoid, where the person may insist others are trying to harm them or steal their possessions. Hallucinations typically involve seeing things that are not there.
Mood and emotional changes manifest as depression, anxiety, or indifference. Apathy, characterized by a lack of interest or motivation, is a common symptom that can hinder participation in daily activities. Emotional lability and irritability are also frequent, reflecting a reduced capacity for emotional regulation due to neurological changes.
Activity disturbances encompass a range of disruptive motor and verbal behaviors. This includes agitation, aggression, and wandering, where a person may pace restlessly or attempt to leave the environment. Sleep disturbances are also prevalent, often resulting in a reversal of the sleep-wake cycle or “sundowning,” where confusion and agitation worsen in the late afternoon and evening.
Identifying Underlying Causes and Triggers
Behavioral and psychological symptoms are rarely random expressions of the disease; they are often a form of communication signaling an unmet need or a reaction to an environmental stressor. Identifying these underlying causes is the first step in effective management.
Internal triggers relate to the person’s physical state and are often overlooked because the individual may struggle to articulate discomfort. Pain is a significant contributor to BPSD, often related to chronic conditions like arthritis or dental issues. Acute medical problems, such as a urinary tract infection (UTI), constipation, or dehydration, can lead to a sudden onset of symptoms or delirium requiring immediate medical attention.
Medication issues, side effects, or withdrawal can also cause or exacerbate BPSD. Basic physiological needs like hunger, thirst, or fatigue can manifest as restlessness or aggression. Addressing these physical causes by checking for fever, pain, or the need for the bathroom is a first intervention.
External and environmental factors frequently trigger BPSD because impaired cognition makes it difficult to process complex stimuli. An environment that is too loud, dimly lit, or unfamiliar can lead to overstimulation and confusion. Conversely, under-stimulation, such as prolonged boredom or isolation, can result in behaviors like repetitive vocalizations or pacing. Changes in routine, a caregiver’s stressed demeanor, or demanding communication can also precipitate a behavioral response.
Non-Drug Approaches to Managing Behaviors
Non-pharmacological strategies are the preferred first-line response to BPSD and focus on understanding the behavior’s meaning before reacting. This approach involves systematically analyzing the events immediately preceding the behavior to determine the cause.
Environmental modification is a powerful tool for reducing triggers and promoting security. Reducing clutter and excessive noise prevents overstimulation, while consistent, soft lighting mitigates confusion, especially during the evening. The physical space should be personalized with familiar objects or photographs to create a welcoming atmosphere that provides comfort and orientation.
Validation and redirection are communication techniques that address the person’s emotional state without resorting to logical arguments. Validation involves acknowledging the person’s feeling, even if the reality they are experiencing is distorted, which defuses distress. A caregiver can then gently shift the person’s focus to a positive, engaging activity or subject (redirection). Since reasoning is often ineffective, these techniques aim to calm the person and move them away from the source of distress.
Establishing predictable daily routines provides structure and reduces anxiety caused by uncertainty. This consistency should extend to mealtimes, waking, and sleeping schedules. Meaningful engagement through activities, such as music therapy, exercise, or simple household tasks, can alleviate boredom and provide a sense of purpose. These structured interventions are individualized to tap into remaining abilities and interests, replacing distress with positive engagement.
When Medical Intervention Is Necessary
The decision to use medication for BPSD is reserved for specific, severe circumstances after non-drug approaches have been exhausted. A thorough clinical assessment is required first to rule out acute medical conditions or delirium causing the behavioral change. Physicians, such as a geriatrician or neurologist, must review the person’s current medications, looking for side effects or drug interactions that could be contributing to the symptoms.
Pharmacological treatments are generally considered only when symptoms pose a persistent danger to the individual or others, or when they cause extreme distress. Antipsychotic medications are the class most often used for severe agitation, aggression, or psychosis that has not responded to other interventions. Antidepressants, such as selective serotonin reuptake inhibitors, may be used for symptoms related to depression or anxiety.
Any use of these medications in older adults with dementia must adhere to a “start low and go slow” principle to minimize adverse effects. The use of atypical antipsychotics carries a significant safety concern, including an increased risk of stroke and mortality. Medication should be carefully monitored, used at the lowest effective dose, and frequently reviewed with the goal of discontinuing the drug if the target symptoms are stable or resolved.