Management of behavioural and psychological symptoms of dementia (BPSD)

For further details see Mental Health Prescribing Forum Prescribing Guideline PG14- Pharmacological Management of Severe Behavioural & Psychological Symptoms of Dementia (BPSD)

Behavioural and psychological symptoms of dementia (BPSD) occur in about 90% of individuals with dementia, causing considerable distress and potentially interfering with the patient care. The presenting neuropsychiatric symptoms include psychosis, agitation, aggression, mood disorder and wandering.

Behaviours that challenge are best managed by good nursing care, the correct environment and use of 'ABC' (antecedents, behaviours and consequences) to try and identify causes and possible triggers for the presenting behaviour for example hunger or pain.

Pharmacological treatment is not a substitute for other approaches and these techniques must always be used concurrently.

Assessment and non-pharmacological management

Non-pharmacological approaches must always be considered first.

For individuals with behaviours that challenge, identify and document target symptoms.

Assess whether symptoms could be a result of:

  • an underlying physical cause (including pain)
  • side-effects of medication
  • an underlying depressive illness and/or anxiety disorder

Once these have been discounted consider appropriate non-pharmacological interventions, for example environmental changes, psychological therapies, multisensory stimulation, massage and aromatherapy.

If symptoms do not resolve consider pharmacotherapy.

Pharmacological Management

Initiation of medication for BPSD (specialist initiated or recommended)

Identify, quantify & document target symptoms including severity and level of distress caused to the individual, including family / carers, and set realistic treatment goals. Suitable assessment tools include Adapted Cohen-Mansfield Agitation Inventory (Adapted CMAI) or Neuropsychiatric Inventory (NPI). The Adapted Cohen-Mansfield Agitation Inventory is available here.

Document which non-pharmacological interventions have been used or offered and complete baseline physical monitoring and cognition assessment.

Communication of information to family/carers

The prescriber must discuss possible treatment options with the individual and/or family / carers, including the anticipated benefits and potential risks of treatment. Cerebrovascular risk factors should be assessed and the possible increased risk of stroke/transient ischaemic attack and possible adverse effects on cognition discussed.

Provide information in an appropriate format to support discussion see Patient focussed resources below.

Recommended treatments

The expected benefits must out-weigh the potential risks/side effects of medication for each individual. Pharmacological management of severe BPSD should only be considered if behaviours cause severe distress to the individual and/or there is immediate risk of harm to other patients or carers.

Once a decision has been reached to start medication for the management of BPSD, the available evidence base is insufficient to support specific recommendations on the preferred choice of medication or indeed the order in which different medicines/different classes of medication should be prescribed.

Medication prescribed for the management of BPSD should be considered as an individual therapeutic trial, with the choice of medication based upon an individual risk-benefit analysis.


The clinical efficacy of antipsychotics is only modest and must be balanced against elevated risk of cerebrovascular adverse events (CVAEs), upper respiratory infections, oedema, extrapyramidal symptoms and an increase in overall mortality rate which applies to all antipsychotics (first and second generation) and not just risperidone and olanzapine.

Risperidone is the only antipsychotic licensed for treatment of dementia-related behavioural disturbances; to be used for short-term treatment (up to 6 weeks) of persistent aggression in moderate to severe Alzheimer's dementia unresponsive to non-pharmacological approaches and where there is risk of harm to the patient or others. The need for continued treatment should be assessed at regular intervals (see below for guidance on monitoring and stopping treatment).

Typical (1st generation) antipsychotics should not be used in BPSD.

Patients with Lewy bodies (DLB) may be extremely sensitive to antipsychotics which may result in a sudden onset of EPSE, profound confusion and deterioration, and can lead to death.

If a patient has a diagnosis of DLB (or diagnosis not excluded), then typical antipsychotics must be avoided and atypical antipsychotics prescribed with extreme caution and should only be prescribed under specialist advice.

As DLB is very similar to Parkinson's Disease dementia the same caution should applied.

The 2009 Banerjee report summarised the risks and benefits of treating 1,000 patients with BPSD with an atypical antipsychotic for around 12 weeks:

  • 91–200 patients with behaviour disturbance (or an additional 72 patients of 1,000 with psychosis) showing clinically significant improvement in these symptoms
  • 10 deaths (evidence suggests that risk of mortality increases over time, longer term treatment may result in up to 167 additional deaths over a 2 year period);
  • 18 CVAEs, around half of which may be severe (evidence from observational studies suggest the increased risk of CVAE may be confined to the 2-3 month period typically encompassed in RCT follow-up studies, therefore extrapolation of data in the original 2004 CSM alert proposing that NNH of 37 from the 8-12 week trial data would translate to NNH of 6.3 over one year, resulting in an additional 159 CVAEs per 1000 people treated, may be an over-estimation).
  • no additional falls or fractures
  • an additional 58–94 patients with gait disturbance

Acetylcholinesterase inhibitors (AChEIs)

Whilst the evidence for the AChEIs in the management of BPSD is equivocal, these agents may be used by specialists if BPSD causes significant distress or potential harm (unlicensed indication).

AChEIs are the preferred treatment option in DLB, and may be considered in Alzheimer's disease or mixed dementias if antipsychotic medication is inappropriate or ineffective. AChEIs should not be used in patients with vascular dementia.


Memantine may have a role in reducing agitation and aggression in BPSD but effect size is small. It may be considered for specialist use in patients with Alzheimer's disease, mixed dementia or DLB who have failed other treatment and who are otherwise prone to rapid decline (unlicensed indication). Not to be used in vascular dementia.


Benzodiazepines may be appropriate for acute, short-term use in all forms of dementia. Be aware of the increased risk of falls.


Antidepressants should only be prescribed in BPSD if an underlying depressive illness or anxiety disorder is present.

Mood stabilisers

Antiepileptic mood stabilisers (carbamazepine and valproate) should only be considered in BPSD associated with Alzheimer's disease, mixed dementia and DLB when all other treatments are inappropriate or ineffective. Not to be used in patients with vascular dementia.

Monitoring and assessment

Treatment should be time-limited and reviewed regularly. Regularly monitor for response to treatment, cognition. Conduct relevant physical checks.

Monitor for emergence of side-effects. People with dementia with Lewy bodies (DLB) have increased sensitivity to antipsychotic side effects, including acute & severe physical deterioration- monitor carefully.

Reviewing and stopping treatment

Reduce & stop medication after 4 weeks if no positive response to treatment observed (or if presentation deteriorates).

Attempt to reduce and stop medication as soon as possible after presenting target symptoms have settled for a period of 3 months (treatment should be regularly reviewed; at least every 3 months or according to clinical need).

Communication with Primary Care

In some circumstances it may be appropriate for the medication to be continued in Primary Care for an agreed period of time, following review by a specialist. Where this is appropriate the specialist will:

  • contact the individual's GP to request that they accept on-going responsibility for prescribing
  • provide the GP with a clear treatment plan to cover the reduction and discontinuation of medication for BPSD and who to contact if they need to seek further advice on the clinical management of the individual (i.e. original symptoms re-emerge on discontinuation of treatment)
  • include a summary of the information documented in the clinical notes regarding target symptoms and choice of medication and rationale for treatment

Patient focussed resources


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