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Behavioural and psychological symptoms of dementia
Agitation, aggression, hallucinations, wandering and sleeplessness in dementia are usually the expression of an unmet need or a physical problem (pain, constipation, urinary retention, infection, a drug); start by looking for the cause and with non-drug management, and reserve an antipsychotic for danger or severe distress, at a low dose and for a short time.
Why it matters in the exam
The exam presents a patient with dementia who has become aggressive or shouts at night and asks for the first step: look for pain, constipation, urinary retention, infection or a new drug, and do not start a drug straight away. Candidates are also asked about the risks of antipsychotics in dementia — increased mortality and stroke — and the need to try to reduce them after several weeks to months.
Recurring points: benzodiazepines worsen confusion and falls; citalopram has been studied for agitation but is capped at 20 mg daily after age 60 owing to QT prolongation; low-dose risperidone is the accepted option for severe persistent aggression in Alzheimer disease; brexpiprazole was approved in the United States (2023) for agitation in Alzheimer disease; and haloperidol is forbidden in dementia with Lewy bodies. According to the American Psychiatric Association guideline, if there is no response within 4 weeks the drug is stopped, and if there is a response a taper is attempted within 4 months.
Behavioural symptoms appear in most patients with dementia at some point in the illness, and they are the common reason for caregiver burnout and moving into an institution. Candidates are also asked about depression and apathy in dementia, which are not the same: apathy lacks initiative and interest without clear sadness, while depression is treated by the usual rules, with caution about anticholinergic drugs.
Key points
- Look for an unmet need or a physical cause — especially pain.
- Non-drug management and caregiver training — first line.
- Antipsychotic only for danger or severe distress, low dose, short time.
- Antipsychotics increase mortality and stroke; attempt to taper within 4 months.
- Benzodiazepines — avoid; in Lewy body dementia — no haloperidol.
Summary table
| Step | What is done | Exam point |
|---|---|---|
| Describe | What the behaviour is, when, where, with whom, what preceded it | Behaviour diary |
| Find the cause | Pain, constipation, urinary retention, infection, hunger, sleep, a new drug, noise | The common cause — unrecognised pain |
| Non-drug management | Routine, lighting, music, activity, caregiver training | First line |
| Antipsychotic | Only for danger or severe distress; low-dose risperidone | Increased mortality and stroke; attempt to taper |
| Others | Citalopram (up to 20 mg over age 60), pain treatment (regular paracetamol) | Benzodiazepines — avoid |
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Sources
- American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia, 2016 — Assessment, indications and tapering
- NICE guideline — Dementia: assessment, management and support, NG97 (2018) — Managing non-cognitive symptoms
- American Geriatrics Society Beers Criteria, 2023 update — Antipsychotics and benzodiazepines in dementia
- Hazzard's Geriatric Medicine and Gerontology, 8th edition (2022) — Behavioural and psychological symptoms of dementia
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.