Behavioural and Psychological Symptoms of Dementia

Behavioural and Psychological Symptoms of Dementia

Impaired Cognition

by Dr Joshua Kua Hai Kiat

Behavioural and psychological symptoms of dementia (BPSD) have been defined as symptoms of disturbed perception, thought content, mood, or behaviour that frequently occur in patients with dementia. They affect almost all people with dementia at some point during the progression of the disorder.1 The prevalence ranges from 61% to 92%.

The pathogenesis of BPSD has not been clearly delineated but it is probably the result of a complex interplay of biological, psychological, social, and environmental factors.

Various BPSD occur at different phases of illness. Mood symptoms are more likely to occur earlier in the course of the illness. Agitated and psychotic behaviours are frequent in patients with moderately impaired cognitive function. However, these become less evident in the advanced stages of dementia, most likely because of the deteriorating physical and neurological condition of the patient.

Early detection of BPSD is extremely important because untreated BPSD can contribute to more caregiver stress2, premature institutionalisation, poorer quality of life for both the caregiver and the patient, excess disability and increased financial cost. Remission or reduction of BPSD, however, is known to produce remarkable improvement in the functional abilities of the patient, delay nursing home placement and improve patients’ and caregivers’ quality of life.

BPSD can be assessed clinically or be rated objectively using standardised instruments which may be either self-rated, caregiver-based or observer reports. These include the Behaviour Pathology in Alzheimer’s Disease (BEHAVE-AD), Neuropsychiatric Inventory (NPI), Cohen-Mansfield Agitation Inventory (CMAI) and the non-cognitive subscale of the Alzheimer’s Disease Assessment Scale (ADAS-Noncog).

Psychotic Symptoms


The prevalence of delusions in people with dementia has been reported to be between 10% and 73%. The delusions are typically less complex and organised than those observed in non-demented psychotic patients.3 Generally, the presence of delusions is a significant predictor of physical aggression.

The types of delusions include:

• Theft

This is probably due to patients not being able to remember the precise location of common household objects and hence form the fertile soil for development of the compensatory delusional ideas of theft.

• Spouse (or other caregiver) is an impostor

This can also be classified as misidentification or as Capgras phenomenon/delusion.

• Infidelity

Occasionally, persons with dementia will become convinced that their spouse is unfaithful – sexually or otherwise, and can lead to aggressive behaviour.


The frequency of hallucinations in people with dementia ranges from 12% to 49%. Visual hallucinations are the most common (occurring in up to 30%), and these symptoms are more common in moderate than in mild or severe dementia. Visual hallucinations are particularly common in subjects with dementia with Lewy bodies (DLB). They are recurrent, and typically consist of well formed images of animals or persons that the patient describes in detail. Patients with dementia may also have auditory hallucinations (up to 10%). One common visual hallucination involves seeing people in the home who are not really there – for example, phantom boarders – that can also be considered as a misidentification syndrome.

Mood Symptoms


Studies show depressed mood to occur most frequently in 40% to 50% of patients with AD, with a major depressive disorder being less common than sub-syndromal depression. There is generally no correlation between cognitive impairment and depression, indicating that the onset of depression might occur at any stage of the disease.

As the dementia progresses, diagnosis of depression becomes more difficult because of the increasing communication difficulties, and because apathy, weight loss, sleep disturbance, and agitation can occur as part of dementia.

Depressive disorder should be considered when one or more of the following conditions are noted: • acute, unexplained behaviour changes

• the patient exhibits a pervasive depressed mood and loss of pleasure

• the family suspects depression

• family or personal history of depression prior to the onset of dementia

• rapid decline in cognition

The Cornell Depression Scale in Dementia specifically assesses depression in dementia and has been shown to be a useful screening instrument in our local population.4


Apathy and related symptoms are among the most common of the BPSD (present in up to 50% in early and intermediate stages of AD and other dementias). Apathy may increase with severity of AD.

Although lack of motivation occurs in apathy and depression, the syndrome of apathy denotes lack of motivation without the dysphoria or vegetative symptoms of depression.


A recent Canadian study found the prevalence of anxiety disorders in Alzheimer’s Disease (AD) and other dementias to be 16% versus 4% in age-matched, non-demented controls.5 Patients with anxiety and dementia may express previously non-manifest concerns about their finances, future and health (including their memory), and worries about previously non-stressful events and activities like being away from home or being left alone. Patients with AD sometimes develop other phobias, such as fear of crowds, travel, the dark, or activities such as bathing.

Motor Function Symptoms


Wandering behaviours include aimless walking and exit seeking/repeatedly attempting to leave the house. It often results in persons having dementia being admitted to a long-term care facility.

Faulty orientation ability, changed environment, memory problem, boredom, excess energy, discomfort/pain, and anxiety may underlie some wandering behaviours. At times, it may just be ‘wondering’ behaviour – the cognitively impaired persons trying to make sense of their environment or searching for people or the past.

Physical Resistance to Care

Resistance to care may involve resisting taking medications or ADL assistance. It is related to the ability of the person with dementia to understand, and thus, it increases in prevalence with worsening of cognitive impairment. It is associated with verbally and physically abusive behaviour towards caregivers.


Its prevalence in persons having dementia increases with degree of cognitive impairment. Agitation in persons having dementia is a complex phenomenon. Neurobiological changes, medical factors, psychological, social, and environmental factors interacting with premorbid personality, influence the development of agitation.

Catastrophic Reaction

Catastrophic reaction is an acute expression of overwhelming anxiety and frustration – often triggered in persons having dementia by adverse experiences such as frustration with getting dressed or with other such experiences. These reactions are also sometimes referred to as rage reactions. They are typically brief and self-limited, and manifest as sudden angry outbursts, verbal aggression (e.g. shouting and cursing), threats of physical aggression, and physical aggression.


Sun-downing is the occurrence and exacerbation of BPSD in the afternoon or evening. Agitation and sleep disturbances commonly accompany sun-downing. Sun-downing increases the burden of care on caregivers, as it often occurs when the staffing in institutional settings is at the lowest levels.

Inappropriate Sexual Behaviours

Inappropriate verbal and physical sexual behaviours involve persistent, uninhibited sexual behaviours directed at oneself or at others. These may take the form of making inappropriate sexual comments to taking their clothes off at inappropriate time or setting to inappropriately touching or molesting others. They are profoundly disruptive to caregivers (family and professional) and other individuals in the immediate surroundings.

Circadian Rhythm Symptoms

Sleep Problems

Sleep pattern changes in dementia include hypersomnia, insomnia, sleep-wake cycle reversal, fragmented sleep, and rapid eye movement sleep behaviour disorder. Patients with dementia often show daytime napping and night-time awakenings associated with poor quality of sleep. Several factors (e.g. pain, need to urinate during the night, medications [diuretics], as well as stimulants such as coffee and bronchodilators), may contribute to this problem.

Appetite and Eating Behavioural Symptoms

Appetite changes can be quantitative (anorexia or hyperphagia) or qualitative (preference for particular foods associated or not to changes in taste). The preference for sweets is particularly frequent in frontotemporal dementia. Most dementia patients lose weight, which can be due to hypermetabolism and inflammatory processes, in relation with hormonal disturbances.


The main objectives in the management of BPSD are to ameliorate the BPSD, maximise functional independence, improve the quality of life of patients, and minimise caregiver stress and distress. Current guidelines recommend non-pharmacological interventions as first-line treatment followed by the least harmful medication for the shortest time possible time.6

The assessment of BPSD requires specific and detailed information about the clinical history, patient’s subjective experiences, and objective behaviour. Information from a reliable caregiver is pertinent.

The doctor should review possible physical causes (delirium, pain, infection, constipation, etc.) as well as the medication list (especially for sedatives and drugs with anticholinergic effects). One should look for contributing environmental factors (e.g. noise associated with shift change). After comprehensive assessment and treatment of underlying medical causes, specific behavioural or psychological symptoms are then identified.

The general principles in management are:

• to understand the cause of the behaviour disturbance (e.g. environmental factors, stressful tasks or caregiver reactions)

• decide if the symptoms need to be treated

• formulate a management plan with the caregiver

• implement specific strategies

• review care plans regularly

Table 1. Pharmacological Interventions

Non-pharmacological interventions are usually first line management for mild to moderate BPSD, and it has been shown that environmental and behavioural interventions in conjunction with caregiver education, training and support are effective.

Pharmacological Management

Medication may be indicated if non-pharmacological interventions have failed or when the symptoms are moderate or severe and has had an adverse impact on the person with dementia or his caregiver.

Guidelines to pharmacotherapy:

• Treat only moderate or severe BPSD with medication.

• Use lower doses especially in the elderly.

• Target specific behaviours e.g. hallucinations, delusions, aggression [see Table 1].

• Start with one drug at a time.

• Be aware of adverse effects and drug sensitivity.

• Regular reviews of medication effects and side effects.

• Make sure use of medication is time limited.

Dr Joshua Kua is Consultant Psychiatrist at Raffles Counselling Centre. In 2001, he received specialist accreditation in psychiatry and obtained his post-graduate diploma (with distinction) in psychotherapy at NUS. He was formerly Chief, Department of Geriatric Psychiatry at the Institute of Mental Health. His clinical interests include adult psychiatry (including stress, depression, anxiety and psychosis), geriatric psychiatry, psycho-oncology, medico-legal/forensic issues (especially mental capacity assessment), counselling and psychotherapy.


1Tariot PN, Mack JL, Patterson MB, Edland SD, Weiner MF, Fillenbaum G, et al. The Behavior Rating Scale for Dementia of the Consortium to Establish a Registry for Alzheimer’s Disease. The Behavioral Pathology Committee of the Consortium to Establish a Registry for Alzheimer’s Disease. Am J Psychiatry 1995; 152: 1349–57

2 Tan LL, Wong HB, Allen H. The impact of neuropsychiatric symptoms of dementia on distress in family and professional caregivers in Singapore. Int Psychogeriatr. 2005 Jun;17(2):253-63.

3 Jeste DV, Meeks TW, Kim DS, Zubenko GS.Review Research agenda for DSM-V: diagnostic categories and criteria for neuropsychiatric syndromes in dementia.J Geriatr Psychiatry Neurol. 2006 Sep; 19(3):160-71.

4 Lam CK, Lim PP, Low BL, Ng LL, Chiam PC, Sahadevan S. Depression in dementia: a comparative and validation study of four brief scales in the elderly Chinese. Int J Geriatr Psychiatry 2004;19(5):422-8.

5 Nabalamba, A., Patten, S.B. Prevalence of mental disorders in a Canadian household population with dementia. Can J Neurol Sci 2010; 37(2): 186–94.

6 Azermai,M., Petrovic,M., Elseviers, M. M.,Bourgeois,J.,Van Bor- tel,L.M.,Vander Stichele,R. H. (2011).Systematic appraisal of dementia guidelines for the management of behavioural an dpsychological symptoms. Ageing Res.Rev. 11, 78–86.

Copyright © 2013 All rights reserved. Content and images are meant for practicing medical doctors, allied health care professionals and other establishments in the medical industry. Reproduction or redistribution of any content and images, is prohibited without the prior written consent of Ezyhealth Media Pte Ltd.