01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Describe behaviour operationally. Replace aggressive with struck a carer during washing on three mornings and record timing, people, noise, touch, pain cues and what followed. Ask whether it distresses the person or primarily the service. Baseline personality and routines, culture, trauma, communication and carer observations make the formulation individual.
Treat sudden change as delirium. Check physiology, glucose, attention, pain, injury, mouth, hearing and vision, constipation, retention, hydration, infection and recent medicines. A positive urine test alone does not explain behaviour. Review anticholinergics, opioids, benzodiazepines, dopaminergic medicines and withdrawal. Multiple triggers are common.
Use communication and environment therapeutically: approach slowly from the front, explain one step, offer a choice, preserve privacy, use familiar staff and music or activity that fits the person's life, provide movement and daylight and protect sleep. Schedule personal care for the best time of day. Avoid arguing with delusions; validate emotion and redirect safely.
For repeated distress, create an antecedent-behaviour-consequence record and test one intervention with a named outcome. OT, nursing, psychology, speech and language, pharmacy and old-age psychiatry contribute. Pain tools designed for limited communication can support but not replace examination. Carers need coaching, respite and a clear crisis contact.
Before antipsychotic treatment, define severe distress or specific harm, confirm non-drug work and exclude DLB, delirium and QT or stroke risk. Support decision-making; if capacity is absent, document best interests and consult representatives. Explain that benefit is uncertain and stroke, death, sedation, falls and aspiration risk increase.
When risperidone's narrow licensed context applies, a frail regimen commonly begins 0.25 mg twice daily and increases by 0.25 mg twice daily no more often than alternate days; 0.5 mg twice daily is typical and 1 mg twice daily is the usual licensed maximum. Limit to six weeks and reassess sooner. Local product and specialist governance is required.
Do not transfer a crisis prescription into indefinite repeat medication. Review target frequency and distress, adverse effects and underlying need after each change and formally at least six-weekly. Reduce and stop if there is no clear benefit or risk has resolved. Re-emergence prompts cause and environment review before automatic restart.
Safeguarding includes the person and carer. Assess whether care demands exceed ability, whether either party is frightened and whether medication is being used as chemical restraint. A capacitous person can accept some risk, but capacity for residence, contact or treatment is assessed specifically. Plan the least restrictive safe support.
Key points
- BPSD is a descriptive umbrella, not a cause: define the exact behaviour, onset, setting, antecedent, consequence and effect on the person.
- First-line assessment is ABCDE and 4AT when acute, then pain, bowel, bladder, infection, medicines, senses, sleep, mood, environment and safeguarding.
- Ask carers what is new, what happens immediately before and what has previously settled the person; obtain the person's perspective with communication support.
- First-line treatment is personalised non-drug care: meet needs, adapt communication and routine, meaningful activity, sensory support, sleep and carer coaching.
- Do not use antipsychotics for wandering, calling out, insomnia, staff convenience or behaviour without severe distress or harm risk.
- NICE restricts antipsychotics to risk of harm or agitation, hallucination or delusion causing severe distress after causes and non-drug care are addressed.
- Discuss increased stroke and mortality risk, choose the lowest dose for the shortest time and document target, capacity or best interests and stop date.
- Risperidone has a narrow short-term licence for persistent aggression in moderate-to-severe Alzheimer disease, generally no longer than six weeks.
- Avoid haloperidol in Parkinson disease and DLB; review all antipsychotics at least every six weeks and stop when no clear ongoing benefit.
- Support and safeguard carers without making them responsible for delivering an unsafe plan or tolerating violence.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Unmet physical need
Pain, dyspnoea, hunger, thirst, toileting, constipation, retention, infection and sleep loss are frequently communicated through changed behaviour.
Dementia network dysfunction
Impaired memory, threat interpretation, inhibition, perception and language make unfamiliar care or internal sensations difficult to understand and express.
Environmental and relational mismatch
Noise, crowding, rushed touch, inconsistent carers, boredom, isolation and routines that ignore personal history can trigger distress.
Medicine and psychiatric contributors
Anticholinergics, sedatives, dopaminergic drugs, withdrawal, depression, anxiety, psychosis and delirium can initiate or amplify symptoms. This increases vulnerability across cognition, function and daily care.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Impaired threat appraisal
Cognitive and perceptual dysfunction can turn personal care, reflections or unfamiliar people into a perceived intrusion requiring defence.
- 2Reduced communication capacity
Pain or need is expressed through pacing, calling out, resistance or aggression when words and sequencing fail.
- 3Frontal-limbic dysregulation
Loss of inhibitory and emotional-control networks contributes to impulsivity, disinhibition, apathy and affective lability. This influences cognition, mobility and everyday functional reserve.
- 4Circadian disruption
Neurodegeneration, inactivity, low daylight and night disturbance fragment sleep and worsen evening confusion and caregiver burden.
- 5Reinforcement cycle
Coercion, restraint and sedating responses increase fear, immobility and delirium, making future care encounters harder. This influences cognition, mobility and everyday functional reserve.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Pacing, shouting or resistance follows pain, personal care, noise, boredom or an unmet toilet need.
Hallucination or delusion causes fear, defensive action or inability to accept essential care.
Reduced initiation and engagement can be mistaken for refusal, depression or laziness and needs mood and environment assessment.
Daytime inactivity and fragmented nights produce evening distress and carer exhaustion.
New behaviour with inattention or arousal change is delirium until assessed.
Carer and person are both frightened, injured or overwhelmed, creating immediate reciprocal risk.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
ABC and 4AT when acuteFirst step - Why
- Detect delirium and instability. within a safe older-adult assessment.
- Interpretation and limitations
- Check physiology and acute attention before assigning a behavioural dementia label.
- 02
Pain and unmet-need assessment - Why
- Find treatable communication drivers. within a safe older-adult assessment.
- Interpretation and limitations
- Examine injury, mouth, joints, abdomen, bladder, bowel, skin, hunger, thirst, breathlessness and fatigue.
- 03
Medication and substance review - Why
- Identify iatrogenic agitation and sedation.
- Interpretation and limitations
- Reconcile anticholinergics, opioids, benzodiazepines, dopamine medicines, recent changes and alcohol or sedative withdrawal.
- 04
Antecedent-behaviour-consequence record - Why
- Define patterns and test interventions.
- Interpretation and limitations
- Record exact event, context, people, time, response and outcome over several episodes rather than using global labels.
- 05
DLB, mood and sensory screen - Why
- Identify high-risk subtype and treatable alternatives.
- Interpretation and limitations
- Ask hallucination phenotype, fluctuation, parkinsonism, REM sleep, depression, anxiety, hearing and vision.
- 06
Antipsychotic safety review - Why
- Establish whether exceptional prescribing is proportionate.
- Interpretation and limitations
- Assess severe distress or harm, capacity, stroke, QT, posture, Parkinson or DLB, interactions and baseline motor and swallow status.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Delirium
Acute fluctuation and inattention from illness or medicines is the priority diagnosis whenever behaviour changes suddenly.
Pain and unmet care need
Arthritis, fracture, dental pain, constipation, retention, hunger and sensory failure may be invisible without structured observation.
Depression or anxiety
Withdrawal, irritability, refusal, sleep change and worry can be treatable mood symptoms rather than inevitable dementia behaviour.
Lewy-body psychosis
Well-formed hallucinations, fluctuation and parkinsonism require DLB assessment and antipsychotic avoidance. Distinguish it through chronology, examination and targeted testing.
Abuse, neglect or environment
Poor care, coercion, overstimulation, loneliness and inappropriate routine can create apparently patient-located symptoms. Distinguish it through chronology, examination and targeted testing.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01First-line formulationName behaviour, trigger and needFirst stepFirst lineA new or recurring behavioural symptom causes concern.+
- 1Treat acute physiology and delirium and obtain collateral on baseline, onset and exact episodes.
- 2Assess pain, unmet need, medicines, mood, senses, environment, communication, carer and safeguarding.
- 3Agree one personalised non-drug intervention with a target and review point.
02Severe distress or harmConsider exceptional short medicine useRisk or severe distress persists despite appropriate non-drug and cause treatment.+
- 1Exclude DLB and major cardiac, stroke and interaction risk and document capacity or best interests and informed risk discussion.
- 2Choose the lowest licensed or specialist-selected dose for the shortest duration against one defined target.
- 3Review effect and toxicity promptly and at least six-weekly and reduce or stop without clear ongoing benefit.
03Carer and safeguarding routePrevent relationship and placement collapseNight supervision, violence, fear or care workload exceeds safe capacity.+
- 1Speak separately with person and carer, assess injury, coercion, willingness, capacity and immediate safety.
- 2Offer carers assessment, respite, training, formal support and adult-safeguarding referral when indicated.
- 3Create an accessible crisis and contingency plan rather than relying on family endurance.
Key medicines and prescribing safety2 treatments · regimens, roles and cautions+
Risperidone
For its narrow licensed context, start 0.25 mg orally twice daily; increase by 0.25 mg twice daily no more often than alternate days, usually to 0.5 mg twice daily and at most 1 mg twice daily, for no longer than six weeks.Discuss stroke and mortality, check Parkinson or DLB, posture, QT and interactions and monitor sedation, falls, rigidity, swallow and infection; stop without clear benefit.
Haloperidol
If its narrow licence and local specialist protocol apply, use the smallest geriatric dose for the shortest possible course after ECG and electrolyte assessment.Contraindicated in Parkinson disease and DLB; monitor QT, extrapyramidal effects, dysphagia, neuroleptic malignant syndrome, stroke and mortality and avoid routine continuation.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Injury and safeguarding crisis
Aggression, wandering, falls, fire and reciprocal carer violence can harm the person and others. Anticipatory multidisciplinary prevention and review are therefore important.
Antipsychotic mortality and stroke
Dementia antipsychotic exposure increases cerebrovascular events and death, alongside sedation, posture, aspiration and extrapyramidal toxicity. Anticipatory multidisciplinary prevention and review are therefore important.
Restraint and functional decline
Restriction and oversedation cause immobility, pressure injury, deconditioning and loss of remaining autonomy. Anticipatory multidisciplinary prevention and review are therefore important.
Carer illness and placement breakdown
Night disturbance, fear and continuous supervision can exhaust carers and precipitate emergency admission. Anticipatory multidisciplinary prevention and review are therefore important.
Unrecognised medical disease
Labelling distress BPSD can delay diagnosis of sepsis, fracture, pain, retention or delirium. Anticipatory multidisciplinary prevention and review are therefore important.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Track the exact target behaviour, frequency, distress, antecedent and function rather than a global calmer impression.
- Review pain, bowel, bladder, sleep, environment and carer delivery whenever symptoms recur.
- After antipsychotic initiation monitor arousal, posture, falls, swallow, rigidity, infection, stroke and actual benefit after each dose change.
- Conduct formal review at least every six weeks and sooner in short licensed courses, with reduction or stop when possible.
- Ask carers privately about sleep, fear and capacity and confirm crisis support before care breaks down.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Behaviour has grammar
Antecedent, action and consequence reveal a modifiable need more often than the label agitation.
Calmer may mean sedated
Reduced movement without less fear, pain or delirium is adverse effect, not therapeutic success.
Wandering is not psychosis
Purposeful walking, searching and restlessness need safety and need-based design, not automatic antipsychotic treatment.
The environment is part of diagnosis
A behaviour confined to bathing, one shift or a noisy ward implicates interaction and setting.
Carers need protection too
Support, respite and safeguarding can be more effective than escalating the person's medication.
Every antipsychotic needs an exit
A target, duration and stop rule prevent an emergency prescription becoming chemical restraint.
11Common pitfallsFrequent interpretation and management errors.
- 01
Using BPSD as the final diagnosis without looking for delirium, pain or unmet need.
- 02
Prescribing antipsychotic for wandering, insomnia or staff convenience.
- 03
Missing DLB neuroleptic sensitivity before haloperidol or risperidone.
- 04
Calling sedation benefit while swallow, mobility and fear worsen.
- 05
Continuing risperidone beyond its narrow six-week licensed course without new justification.
- 06
Expecting an exhausted carer to absorb escalating night and violence risk without support.