Management of Behavioral and Psychological Symptoms in Dementia

  • Michelle Braun
Part of the Clinical Handbooks in Neuropsychology book series (CHNEURO)


Behavioral and psychological symptoms are common in dementia, challenging to manage, and a leading cause of nursing home placement, decreased quality of life, and caregiver distress. This chapter provides a seven-step model for tailoring treatment of five common behavioral and psychological symptoms of dementia (BPSD): agitation/irritability/aggression, depression and anxiety, apathy, sleep disturbance, and wandering. A review of nonpharmacological and pharmacological interventions and practical strategies for addressing BPSD in the context of neuropsychology practice are included.


Dementia Behavior management Psychological symptoms Alzheimer’s 


  1. 1.
    2016 Alzheimer’s disease facts and figures. Retrieved July 1, 2017.
  2. 2.
    Managing behavioral and psychological symptoms of dementia. Retrieved July 1, 2017.
  3. 3.
    Cummings J, Lai TJ, Hemrungrojn S, Mohandas E, Yun Kim S, Nair G, et al. Role of donepezil in the Management of Neuropsychiatric Symptoms in Alzheimer’s disease and dementia with Lewy bodies. CNS Neurosci Ther. 2016;22:159–66.CrossRefGoogle Scholar
  4. 4.
    Zhao QF, Tan L, Wang HF, Jiang T, Tan MS, Tan L, et al. The prevalence of neuropsychiatric symptoms in Alzheimer’s disease: systematic review and meta-analysis. J Affect Disord. 2016;190:264–71.CrossRefGoogle Scholar
  5. 5.
    Borsje P, Wetzels RB, Lucassen PL, Pot AM, Koopmans RT. The course of neuropsychiatric symptoms in community-dwelling patients with dementia: a systematic review. Int Psychogeriatr. 2015;27:385–405.CrossRefGoogle Scholar
  6. 6.
    van der Linde RM, Matthews FE, Dening T, Brayne C. Patterns and persistence of behavioural and psychological symptoms in those with cognitive impairment: the importance of apathy. Int J Geriatr Psychiatry. 2017;32:306–15.CrossRefGoogle Scholar
  7. 7.
    Brodaty H, Connors MH, Xu J, Woodward M, Ames D. The course of neuropsychiatric symptoms in dementia: a 3-year longitudinal study. J Am Med Dir Assoc. 2015;16:380–7.CrossRefGoogle Scholar
  8. 8.
    Apostolova LG, Di LJ, Duffy EL, Brook J, Elashoff D, et al. Risk factors for behavioral abnormalities in mild cognitive impairment and mild Alzheimer’s disease. Dement Geriatr Cogn Disord. 2014;37:315–26.CrossRefGoogle Scholar
  9. 9.
    D’Onofrio G, Sancarlo D, Panza F, Copetti M, Cascavilla L, Paris F, et al. Neuropsychiatric symptoms and functional status in Alzheimer’s disease and vascular dementia patients. Curr Alzheimer Res. 2012;9:759–71.CrossRefGoogle Scholar
  10. 10.
    Cohen-Mansfield J, Marx M, Dakeel-Ali M, Regier MG, Thein K. Can persons with dementia be engaged with stimuli? Am J Geriatr Psychiatry. 2010;18:351–62.CrossRefGoogle Scholar
  11. 11.
    Guarlnik JM, Levielle S, Volpato S, Marx M, Cohen-Mansfield J. Targeting high-risk older adults into exercise programs for disability prevention. J Aging Phys Act. 2003;11:219–28.CrossRefGoogle Scholar
  12. 12.
    Cohen-Mansfield J. Use of patient characteristics to determine nonpharmacologic interventions for behavioral and psychological symptoms of dementia. Int psycho geriatr. 2000;12:373–80.CrossRefGoogle Scholar
  13. 13.
    Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. 2015;350:h369.CrossRefGoogle Scholar
  14. 14.
    Fisher JE, Harsin CW, Hayden JE. Behavioral interventions for patients with dementia. In: Molinari V, editor. Professional Psychology in long-term care. New York: Hatherleigh; 2000. p. 179–200.Google Scholar
  15. 15.
    Alzheimer’s Association 24/7 Helpline webpage. Accessed July 1, 2017.
  16. 16.
    Gitlin LN, Rose K. Impact of caregiver readiness on outcomes of a nonpharmacological intervention to address behavioral symptoms in persons with dementia. Int J Geriatr Psychiatry. 2016;31:1056–63.CrossRefGoogle Scholar
  17. 17.
    Parker D, Mills S, Abbey J. Effectiveness of interventions that assist caregivers to support people with dementia living in the community: a systematic review. Int J Evid Based Healthc. 2008;6:137–72.PubMedGoogle Scholar
  18. 18.
    Health Quality Ontario. Caregiver- and patient-directed interventions for dementia: an evidence-based analysis. Ont Health Technol Assess Ser. 2008;8:1–98.Google Scholar
  19. 19.
    Cohen-Mansfield J, Marx M, Thein K, Dakeel-Ali M. The impact past and present preferences on stimulus engagement in nursing home residents with dementia. Age & Mental Health. 2010;14:67–73.CrossRefGoogle Scholar
  20. 20.
    Cohen-Mansfield J, Thein K, Dakeel-Ali M, Marx M. The underlying meaning of stimuli: impact on engagement of persons with dementia. Psychiatry Res. 2010;177:216–22.CrossRefGoogle Scholar
  21. 21.
    Chancellor B, Duncan A, Chatterjee A. Art therapy for Alzheimer’s disease and other dementias. J Alz Dis. 2014;39:1–11.CrossRefGoogle Scholar
  22. 22.
    Camic PM, Tischler V, Pearman CH. Viewing and making art together: A multi-session art-gallery based intervention for people with dementia and their carers. Aging Ment Health. 2014;18:161–8.CrossRefGoogle Scholar
  23. 23.
    Cohen-Mansfield J, Thein K, Dakeel-Ali M, Regier MG, Marx M. The value of social attributes of stimuli in promoting engagement in persons with dementia. J Nerv Ment Dis. 2010;198:586–92.CrossRefGoogle Scholar
  24. 24.
    Abraha I, Rimland JM, Lozano-Montoya I, Dell’Aquila G, Vélez-Díaz-Pallarés M, Trotta FM, et al. Simeulated presence therapy for dementia. Cochrane database Syst rev. 2017;18:4.Google Scholar
  25. 25.
    Wu J, Wang Y, & Wang Z. The effectiveness of massage and touch on behavioural and psychological symptoms of dementia: a quantitative systematic review and meta-analysis. J Adv Nurs 2017;5. doi: [Epub ahead of print].CrossRefGoogle Scholar
  26. 26.
    Abd El-Kader SM, Al-Jiffri OH. Aerobic exercise improves quality of life, psychological Well-being and systemic inflammation in subjects with Alzheimer’s disease. Afr Health Sci. 2016;16:1045–55.CrossRefGoogle Scholar
  27. 27.
    Morris JK, Vidoni ED, Johnson DK, Van Sciver A, Mahnken JD, Honea RA, et al. Aerobic exercise for Alzheimer’s disease: a randomized controlled pilot trial. PLoS One. 2017;12:e0170547.CrossRefGoogle Scholar
  28. 28.
    Cohen-Mansfield J, Lipson S. Pain in cognitively impaired nursing home residence: how well are physicians diagnosing it? J Am Ger Soc. 2002;50:1039–44.CrossRefGoogle Scholar
  29. 29.
    McGee JS, Zhao HC, Myers DR, Kim SM. Positive psychological assessment and early-stage dementia. Clin Gerontol. 2017;9:1–13.Google Scholar
  30. 30.
    Millán-Calenti JC, Lorenzo-López L, Alonso-Búa B, de Labra C, González-Abraldes I, Maseda A. Optimal nonpharmacological management of agitation in Alzheimer’s disease: challenges and solutions. Clin Interv Aging. 2016;11:175–84.CrossRefGoogle Scholar
  31. 31.
    Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors and dementia: a review, summary, and critique. Am J Geriatr Psychiatry. 2001;9:361–81.CrossRefGoogle Scholar
  32. 32.
    Cohen-Mansfield J, Liben A, Marx M. Nonpharmacologic treatment of agitation: A controlled trial of systematic individualized intervention. J Gerontol: Series A. 2007;62:908–16.CrossRefGoogle Scholar
  33. 33.
    de Oliveira, Radanovic M, Homem de Mello PC, Buchain PC, Vizzotto ADB, Celestino DL et al. Nonpharmacological interventions to reduce behavioral and psychological symptoms of dementia: a systematic review. BioMed Res Intl. 2015;Art ID 218980.Google Scholar
  34. 34.
    Pedersen SKA, Andersen PN, Lugo RG, Andreassen M, Sütterlin S. Effects of music on agitation in dementia: a meta-analysis. Front Psychol. 2017;8:742.CrossRefGoogle Scholar
  35. 35.
    Travers C, Brooks D, Hines S, O’Reilly M, McMaster M, He W, et al. Effectiveness of meaningful occupation interventions for people living with dementia in residential aged care: a systematic review. JBI Database System Rev Implement Rep. 2016;14:163–225.CrossRefGoogle Scholar
  36. 36.
    Abraha I, Rimland JM, Trotta FM, Dell’Aquila G, Cruz-Jentoft A, Petrovic M, et al. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series. BMJ Open. 2017;16:e012759.CrossRefGoogle Scholar
  37. 37.
    Dourado MC, Laks J. Psychological interventions for neuropsychiatric disturbances in mild and moderate Alzheimer’s disease: current evidences and future directions. Curr Alzheimer Res. 2016;13:1100–11.CrossRefGoogle Scholar
  38. 38.
    Moorman Li R, Gilbert B, Orman A, Aldridge P, Leger-Krall S, Anderson C, et al. Evaluating the effects of diffused lavender in an adult day care center for patients with dementia in an effort to decrease behavioral issues: a pilot study. J Drug Assess. 2017;6:1–5.CrossRefGoogle Scholar
  39. 39.
    Ng QX, Ho CY, Koh SS, Tan WC, Chan HW. Doll therapy for dementia sufferers: a systematic review. Complement Ther Clin Pract. 2017;26:42–6.CrossRefGoogle Scholar
  40. 40.
    Richeson NE. Effects of animal-assisted therapy on agitated behaviors and social interactions of older adults with dementia. Am J Alzheimers Dis Other Dem. 2003;18:353–8.CrossRefGoogle Scholar
  41. 41.
    Liben A, Cohen-Mansfield J. Therapeutic robocat for nursing home residents with dementia: preliminary inquiry. Am J Alzheimers Dis Other Dem. 2004;19:111–6.CrossRefGoogle Scholar
  42. 42.
    Steinberg M, Lyketsos CG. Atypical antipsychotic use in patients with dementia: managing safety concerns. Am J Psychiatr. 2012;169:900–6.CrossRefGoogle Scholar
  43. 43.
    Dorsey RE, Rabbani A, Gallagher SA, Conti RM, Alexander GC. Impact of FDA black-box advisory on antipsychotic medication use. Arch Int Med. 2010;170:96–103.CrossRefGoogle Scholar
  44. 44.
    Gabryelewicz T. Pharmacological treatment of behavioral symptoms in dementia patients. Przegl Lek. 2014;71(4):215–20.PubMedGoogle Scholar
  45. 45.
    Manabe Y, Ino T, Yamanaka K, Kosaka K. Increased dosage of donepezil for the management of behavioural and psychological symptoms of dementia in dementia with Lewy bodies. Psychogeriatrics. 2016;16:202–8.CrossRefGoogle Scholar
  46. 46.
    Suzuki H, Inoue Y, Nishiyama A, Mikami K, Gen K. Clinical efficacy and changes in the dosages of concomitantly used psychotropic drugs in memantine therapy in Alzheimer’s disease with behavioral and psychological symptoms on dementia. Ther Adv Psychopharmacol. 2013;3:123–8.CrossRefGoogle Scholar
  47. 47.
    Ballard CG, Gauthier S, Cummings JL, Brodaty H, Grossberg GT, Robert P, et al. Management of agitation and aggression associated with Alzheimer disease. Nat Rev Neurol. 2009;5:245–55.CrossRefGoogle Scholar
  48. 48.
    Siddique H, Hynan LS, Weiner MF. Effect of a serotonin reuptake inhibitor on irritability, apathy, and psychotic symptoms in patients with Alzheimer’s disease. J Clin Psychiatry. 2009;70:915–8.CrossRefGoogle Scholar
  49. 49.
    Leonpacher AK, Peters ME, Drye LT, Makino KM, Newell JA, Devanand DP. Effects of Citalopram on Neuropsychiatric Symptoms in Alzheimer’s Dementia: Evidence from the CitAD study. Am J Psychiatry. 2016;173:473–80.CrossRefGoogle Scholar
  50. 50.
    Porsteinsson AP, Keltz MA, Smith JS. Role of citalopram in the treatment of agitation in Alzheimer’s disease. Neurodegener Dis Manag. 2014;4:345–9.CrossRefGoogle Scholar
  51. 51.
    Porsteinsson AP, Antonsdottir IM. An update on the advancements in the treatment of agitation in Alzheimer’s disease. Expert Opin Pharmacother. 2017;18:611–20.CrossRefGoogle Scholar
  52. 52.
    Isserles M, Daskalakis ZJ, Kumar S, Rajji TK, Blumberger DM. Clinical effectiveness and tolerability of electroconvulsive therapy in patients with neuropsychiatric symptoms of dementia. J Alzheimers Dis. 2017;57:45–51.CrossRefGoogle Scholar
  53. 53.
    Teri L, Logsdon RG, Uomoto J, McCurry SM. Behavioral treatment of depression in dementia patients: a controlled clinical trial. J Gerontol B Psychol Sci Soc Sci. 1997;52B:P159–66.CrossRefGoogle Scholar
  54. 54.
    Gómez GM, Gómez GJ. Music therapy and Alzheimer’s disease: cognitive, psychological, and behavioural effects. Neurologia. 2017;32:300–8.CrossRefGoogle Scholar
  55. 55.
    Ray KD, Mittelman MS. Music therapy: a nonpharmacological approach to the care of agitation and depressive symptoms for nursing home residents with dementia. Dementia (London). 2015. pii: 1471301215613779. [Epub ahead of print].Google Scholar
  56. 56.
    Sánchez A, Maseda A, Marante-Moar MP, de Labra C, Lorenzo-López L, Millán-Calenti JC. Comparing the effects of multisensory stimulation and individualized music sessions on elderly people with severe dementia: a randomized controlled trial. J Alzheimers Dis. 2016;52:303–15.CrossRefGoogle Scholar
  57. 57.
    Orgeta V, Tabet N, Nilforooshan R, Howard R. Efficacy of antidepressants for depression in alzheimer’s disease: systematic review and meta-analysis. J Alzheimers Dis. 2017;58:725–33.CrossRefGoogle Scholar
  58. 58.
    Theleritis C, Siarkos K, Katirtzoglou E, Politis A. Pharmacological and nonpharmacological treatment for apathy in Alzheimer disease: a systematic review across modalities. J Geriatr Psychiatry Neurol. 2017;30:26–49.CrossRefGoogle Scholar
  59. 59.
    Theleritis PA, Siarkos K, Lyketsos CG. A review of neuroimaging findings of apathy in Alzheimer’s disease. Int Psychogeriatr. 2014;26:195–207.CrossRefGoogle Scholar
  60. 60.
    Brodaty HM, Burns KB. Nonpharmacological management of apathy in dementia: a systematic review. Am J Geriatr Psychiatry. 2002;20:549–64.CrossRefGoogle Scholar
  61. 61.
    Ferrero-Arias J, Goñi-Imízcoz M, González-Bernal J, Lara-Ortega F, da Silva-González Á, Díez-Lopez M. The efficacy of non-pharmacological treatment for dementia related apathy. Alzheimer Dis Assoc Dis. 2011;25:213–9.CrossRefGoogle Scholar
  62. 62.
    Deschenes CL, McCurry SM. Current treatments for sleep disturbances in individuals with dementia. Curr Psychiatry Rep. 2009;11:20–6.CrossRefGoogle Scholar
  63. 63.
    McCleery J, Cohen DA, Sharpley AL. Pharmacotherapies for sleep disturbances in dementia. Cochrane Database Syst Rev. 2016;11:CD009178.PubMedGoogle Scholar
  64. 64.
    Davis R, Weisbeck C. Creating a supportive environment using cues for wayfinding in dementia. J Gerontol Nurs. 2016;42:36–44.CrossRefGoogle Scholar
  65. 65.
    Topfer LA. GPS locator devices for people with dementia. In: CADTH Issues in Emerging Health Technologies. Canadian Agency for Drugs and Technologies in health: Ottawa (ON); 2016. p. 147.Google Scholar
  66. 66.
    Futrell MF, Devereaux Melillo K, Remington R. Evidence-based practice guideline: wandering. J Geron Nurs. 2014;40:16–23.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Michelle Braun
    • 1
  1. 1.Department of Neurology and NeurosurgeryAscension – Wheaton Franciscan HealthcareRacineUSA

Personalised recommendations