Synopsis
Formulate distress and behaviour in dementia through unmet need and delirium assessment, use antipsychotics only within strict risk criteria, and apply decision-specific Mental Capacity Act practice.
- Describe the behaviour precisely—who, when, where, trigger, duration and consequence—rather than using 'challenging behaviour' as a diagnosis.
- Before treatment perform a structured assessment for pain, delirium, infection, hunger, thirst, constipation, urinary retention, sleep, sensory loss, environment and communication.
- Offer psychosocial and environmental interventions first when there is no emergency, matching meaningful activity, routine, lighting, noise and carer approach to the person.
Key red flags
Acute fluctuating attention, altered arousal, sleep-wake reversal or new perceptual symptoms over hours to days indicates urgent delirium assessment even with established dementia.
Investigation priorities
Find acute illness, pain and physiological causes behind new behavioural change.
Management branches
Distress, agitation, wandering, resistance or perceptual symptoms emerge or worsen.
- Define onset and behaviour precisely, assess immediate harm and perform urgent delirium, pain, retention, constipation, infection and medicine review.
- Ask what happens immediately before and after episodes, including staff language, personal-care task, noise, lighting, hunger and sensory access.
Key medicines
RisperidoneIf strictly indicated, use a low geriatric starting dose and titrate cautiously; the licensed persistent-aggression course in Alzheimer disease is limited to 6 weeks.
HaloperidolUse only the lowest effective short-term dose within its narrow licence and local specialist protocol after ECG and interaction risks are considered.