Behavioral and psychological
symptoms of dementia(BPSD) and
Senior Resident Academic
Department of Neurology
• Behavioral changes, paranoid
delusions, hallucinations and long periods of
screaming were described by Alzheimer in
1907 in his original case description of the
• An integral part of dementia syndrome.
• BPSD is associated with a more rapid rate of
cognitive decline and greater impairment in
activities of daily living.
• A burden to patients and care givers.
• Costs significantly to overall cost of dementia
• Most of them are treatable.
• Reported prevalence of BPSD ranges from 50%100%.
• BPSD were severe in 36.6% of the
patients, moderate in 49.3%, and mild in 14.1%.
• Depression, apathy and anxiety were the most
• Depending upon cognitive levels, variation in
BPSD frequencies have been reported.
– 92.5% in patients with a MMSE between 11 and 20.
– 84% of the patients with a MMSE between 21 and 30.
FEATURES OF BPSD:
• Myriad manifestations.
• Inappropriate behaviors:
– Physically aggressive behavior : hitting, kicking or
– Physically nonaggressive behavior: pacing or
inappropriately handling objects
– Verbally non aggressive agitation: constant
repetition of sentences or requests.
– Verbal aggression: cursing or screaming
• 24% and 48% of dementia patients have
motor behavioural abnormalities.
• Physical violence and hitting occurs in
approximately 30% in Alzheimer’s dementia
• Predictors of aggressive behavior:
– Premorbid history of aggression
– Troubled premorbid relationship between
caregiver and patient
– Multiple problems.
– Quarter fo AD patients have wandering.
– Elderly wanderers have language impairment,
disorientation and hyperactivity compared to non
– Wanders exhibit better social skills and are less
• Mood Disturbances:
– Depression is common.
– may not have a typical presentation.
– lack of sad or depressed affect.
• Depressive cognitions, death wishes are
• Anxiety, fear, irritability, anger are also seen.
• Apathy : 70-90% of AD.
• Syndrome of decreased initiation and
motivation, decreased social
indifference, diminished reactivity and lack of
• Apathy or Depression?
– Dysphoria, hopelessness, guilt, self-criticism,
suicidal ideation, sleep problems and appetite
disturbances are associated with depression.
• Personality change:
– Increasing passivity, coarsening of affect,
decreased spontaneity, inactivity, feelings of
insecurity, less cheerfulness and responsiveness.
– Reduced initiative and drive, grossly insensitive
behavior, lack of restraint, disinhibition, sexual
misadventure, indolence, foolish jokes and pranks
• Psychotic features:
– usually paranoid in nature.
– some one is stealing things, being present in the
room, living inappropriately in the home
(phantom boarder), mishandling personal
finances, planning to harm physically.
– delusions of
infidelity, hypochondriasis, zoopathy, dead
relatives being still alive, erotomania, Capgras
syndrome, believing television images are
real, personal images in a mirror is a different
person, misidentifying own home.
• Other symptoms:
– Screaming is seen in 25%.
– high degree of dependency for ADL.
– Sleep disturbance.
– Dependency for excretory functions and hygiene
maintenance come as a burden to caregivers.
TYPES OF DEMENTIA AND BPSD:
• Some type of BPSD are more common in
certain type dementia.
– Aspontaneity and reduced initiative in early
– Behavioral symptoms occur ad disease progress.
– Aggression, wandering, incontinence, and at least
one symptom of Klüver-Bucy syndrome was found
– Visual hallucinations- more complex, vivid and
– Auditory hallucinations, persecutory delusions.
– Judgment and insight is relatively preserved.
– Extreme anxiety and depression.
– Lability and explosive emotional outbursts,
episodes of noisy weeping or laughing
• Pick’s dementia:
– Changes of character and social behavior more.
– Fatuous euphoria or apathy,insensitive behavior, lack
of restraint, and sexual misadventure have been seen.
– Hypermetamorphosis occur early than AD.
• Dementia due to Huntington’s disease:
– Emotional disturbance is a prominent premonitory
– BPSD are reported for some considerable time before
– Paranoid developments may be earliest manifestation.
– Delusions of persecution, religiosity, reference and
grandiosity are common.
– schizophrenic or paraphrenic illness may be present
for years before HD.
• Creutzfeldt-Jakob disease (CJD):
– characterized by neurasthenic symptoms.
– Fatigue, insomnia, anxiety, depression, mental
– slowness and unpredictability of behavior,
auditory hallucinations and delusions are the
• Alcoholic dementia:
– Profound social disorganization
– Deterioration of personality.
ETIOLOGY OF BPSD:
• Various theoretical models have been
• ‘Unmet needs’ model
• A behavioral/learning model
• Environmental vulnerability/reduced stressthreshold model.
• Premorbid personality has also been linked to
• It has been suggested that some BPSD could
be the consequence of both dementia and an
undiagnosed comorbid bipolar spectrum
disorder or a pre-existing bipolar diathesis
pathoplastically altering the clinical expression
• An imbalance of different neurotransmitters
(acetylcholine, dopamine, noradrenaline, sero
tonin,GABA) has been proposed as the
neurochemical correlate of BPSD.
– increased norepinephrine (NE) activity and/or
hypersensitive adrenoreceptors compensating for
loss of NE neurons – in AD
– Increased activity of dopaminergic
neurotransmission and altered serotonergic
modulation of dopaminergic neurotransmission is
associated with agitated and aggressive behavior
• DAT1 3’-UTR VNTR polymorphism may play a
role in BPSD susceptibility.
• Depends on history from care giver.
• Specific assessment scales are available.
– Apathy Evaluation Scale (AES)
– Behavioural Rating Scale for Geriatric Patients
– Behaviour Pathology in Alzheimer’s Disease Rating Scale (BEHAVEAD)
– Behavioural Rating Scales for Dementia
– Cohen-Mansfield Agitation Inventory (CMAI)
– Cornell Scale for Depression in Dementia (CSDD)
– Frontal Systems Behaviour Inventory (FrSBe)
– Neuropsychiatric Inventory (NPI)
– Neuropsychiatric Inventory– Nursing Home version (NPI-NH)
– Apathy Inventory (AI)
– Behavioural and Psychological Symptoms Questionnaire (BPSQ).
MANAGEMENT OF BPSD:
• Psychological, behavioral, environmental, and
• Nonpharmacological intervention is the
preferred initial method of intervention for
• Environment around the patient can be modified
for a beneficial effect on the BPSD.
• Simulated home environment with appropriate
visual, auditory and olfactory stimuli which may
decrease the chance of trespassing, exit seeking
and other agitation behaviors.
• Reduced stimulation environments.
• Environment can be modified by installing
adequate daytime lighting to improve sleep
patterns in patients with disturbed sleep wake
• One to one interaction for 30 min per day for
10 days has been found to be effective in
decreasing verbally disruptive behavior.
• Regular intensive interaction help in reality
• Socialization can be increased by group
activity, conjoint tasks and simple games.
• Displaying photos of near relatives.
• Pet therapy.
Minimize the impact of sensory
• Corrective eyeglasses and hearing aids
decrease risk of disorientation.
• Slow and repetitive explanations reduce
confusion and agitation.
Medical and nursing interventions:
• Prompt management of pain is helpful.
• Adequate sleep hygiene – decreases agitation.
• Agitation secondary to fatigue and circadian
rhythm disturbances can be reduced by bright
• Music therapy has been shown to be effective
to reduce BPSD in patients with moderatesevere dementia.
• Extinction, differential reinforcement and
• Reinforcements include social
reinforcements, food, touch, going
• Consistent daily routines.
• Exercises, removal of restraints, and adequate
rest help in reducing the inappropriate
• Spiritual and religious activities.
• Nilamadhab Kar; Behavioral and psychological symptoms of
dementia and their management; Indian J Psychiatry. 2009
January; 51(Suppl1): S77–S86.
• Manjari Tripathi, Deepti Vibha; An approach to and the
rationale for the pharmacological management of behavioral
and psychological symptoms of dementia; IAN 2010; 9
• Franz Müller-Spahn,MD; Behavioral disturbances in
• Bradley's Neurology in Clinical Practice, 6th edition