Synopsis
Interpret agitation, aggression, psychosis, wandering, apathy and sleep disturbance as communication requiring trigger assessment, use personalised non-drug care first, protect carers and restrict antipsychotics to severe distress or harm with explicit review and stop plans.
- 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.
Key red flags
Hours-to-days behaviour change, drowsiness or inattention is delirium until assessed, not a new BPSD baseline.
New behaviour with inattention or arousal change is delirium until assessed.
Investigation priorities
Detect delirium and instability. within a safe older-adult assessment.
Management branches
A new or recurring behavioural symptom causes concern.
- Treat acute physiology and delirium and obtain collateral on baseline, onset and exact episodes.
- Assess pain, unmet need, medicines, mood, senses, environment, communication, carer and safeguarding.
Key medicines
RisperidoneFor 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.
HaloperidolIf its narrow licence and local specialist protocol apply, use the smallest geriatric dose for the shortest possible course after ECG and electrolyte assessment.