Key Facts

BPSD are a major cause of distress for patients and carers, and are the primary reason for care home admission. Non-pharmacological approaches are always first-line.

Epidemiology

Up to 90% of people with dementia experience BPSD. Approximately 850,000 people have dementia in the UK, projected to rise to 1.6 million by 2040. BPSD accounts for a significant proportion of the economic cost of dementia care.

Aetiology

BPSD arise from interaction of:

• Neurobiological factors: Neurodegeneration affecting frontal lobes (disinhibition), temporal lobes (psychosis), cholinergic/serotonergic/dopaminergic dysfunction
• Psychological factors: Premorbid personality, coping mechanisms, unmet psychological needs
• Environmental factors: Overstimulation, understimulation, unfamiliar environment, change in routine
• Physical factors: Pain, infection, constipation, delirium, medication side effects

Pathophysiology

• Alzheimer's disease: Cholinergic deficit, amyloid plaques, neurofibrillary tangles → progressive cognitive decline with BPSD
• Lewy body dementia: Visual hallucinations, fluctuating cognition, parkinsonism — extremely sensitive to antipsychotics (can cause severe neuroleptic sensitivity reactions)
• Frontotemporal dementia: Prominent behavioural changes (disinhibition, apathy, stereotyped behaviour) — often before memory loss
• Vascular dementia: Stepwise decline, focal neurology, emotional lability

Common BPSD

• Apathy: Most common; reduced motivation and engagement
• Agitation/aggression: Physical or verbal; often worst in late afternoon ('sundowning')
• Depression: Low mood, tearfulness, withdrawal
• Anxiety: Fear, worry, restlessness
• Psychosis: Visual hallucinations (especially Lewy body), persecutory delusions
• Sleep disturbance: Reversed sleep-wake cycle
• Wandering: Purposeless walking; exit-seeking or aimless
• Disinhibition: Inappropriate sexual behaviour, loss of social boundaries (especially FTD)
• Repetitive behaviours: Vocalisations, questions, actions

Red Flags — Exclude Before Attributing to BPSD

• Delirium: Acute onset, fluctuating consciousness, medical cause
• Pain: Undertreated — use Abbey Pain Scale for non-verbal patients
• Infection: UTI, pneumonia (very common precipitants)
• Constipation: Frequently overlooked cause of agitation
• Medication side effects: Anticholinergics, opioids, steroids
• Environmental change: New care setting, change of carer

Bedside

• 4AT or AMT: Delirium screening (essential before attributing symptoms to BPSD)
• Abbey Pain Scale: Pain assessment in non-verbal patients
• NPI (Neuropsychiatric Inventory): Gold standard BPSD assessment tool
• ABC chart: Antecedent-Behaviour-Consequence — identify triggers
• Physical examination: Infection screen, constipation check, medication review

Bloods

• FBC, CRP, U&Es: Infection, dehydration
• Urine MC&S: UTI (common trigger)
• TFTs, calcium, B12, folate, glucose: Treatable causes of cognitive/behavioural change
• LFTs: Hepatic encephalopathy

Imaging

• CT/MRI brain: Exclude structural cause if not previously investigated

Special Tests

• Cognitive assessment: MMSE, MoCA, ACE-III — establish baseline and trajectory
• Medication review: Rationalise polypharmacy, identify iatrogenic causes

Non-pharmacological (Always first-line — NICE NG97)

• Person-centred care: Life story work, meaningful activities, validation therapy
• Environmental modifications: Reduce noise, adequate lighting, familiar objects, signage
• Structured activities: Music therapy, reminiscence therapy, art therapy, animal-assisted therapy
• Communication strategies: Simple language, calm tone, non-verbal cues
• Carer support: Education, respite, support groups (Alzheimer's Society)
• Pain management: Ensure adequate analgesia — trial of paracetamol 1g QDS if pain suspected
• Sleep hygiene: Light exposure, reduce daytime napping, evening routine

Pharmacological (NICE NG97 — only if severe distress/risk)

• Treat underlying cause first: Infection, pain, constipation, delirium
• Cholinesterase inhibitors: Donepezil 5-10mg OD — may reduce BPSD in Alzheimer's and Lewy body dementia
• Antipsychotics (severe aggression/psychosis causing significant distress or risk):
  • Risperidone 0.25-1mg (only licensed antipsychotic for BPSD) — short-term (up to 6 weeks), then review
  • Risks: 2× stroke risk, 1.5× mortality risk, falls, sedation, parkinsonism
  • Avoid in Lewy body dementia — severe neuroleptic sensitivity (use quetiapine low-dose if essential)
• Memantine 10-20mg: May help agitation in moderate-severe Alzheimer's
• SSRIs: Sertraline/citalopram for depression in dementia
• Trazodone 25-100mg: For agitation and sleep disturbance (off-label, limited evidence)

Referral Criteria

• Persistent BPSD despite non-pharmacological approaches — old age psychiatry
• Diagnostic uncertainty — memory assessment service
• Carer stress/burnout — social services, carer support
• Safeguarding concerns — safeguarding team

• BPSD typically fluctuate and change over the course of dementia
• Apathy tends to worsen as dementia progresses
• Psychosis is more common in moderate-severe stages
• Agitation is the most common reason for care home admission
• Antipsychotic use: ~2 additional deaths per 100 patients treated for 12 weeks; use should be minimised
• Non-pharmacological interventions: Evidence supports music therapy, structured activities, and person-centred care in reducing BPSD

BPSD Management Algorithm

Antipsychotic Risks in Dementia