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.
- 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.
Key red flags
Hours-to-days behaviour change, drowsiness or inattention is delirium until assessed, not a new BPSD baseline.
Pain, retention, constipation, hunger, thirst, hypoxia, infection and medicine toxicity must be checked before psychotropic treatment.
Hallucinations with parkinsonism, fluctuation or REM-sleep behaviour suggests DLB and potentially fatal antipsychotic sensitivity.
Suicide intent, weapons, serious assault, fire-setting or unsafe wandering requires an immediate risk and safeguarding plan.
Bruising, fear of a carer, overmedication or reciprocal violence requires private enquiry and adult-safeguarding consideration.
Antipsychotic sedation, rigidity, dysphagia, stroke symptoms, fever or falls requires urgent review and usually cessation.
New behaviour with inattention or arousal change is delirium until assessed.
Carer and person are both frightened, injured or overwhelmed, creating immediate reciprocal risk.
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.
- Agree one personalised non-drug intervention with a target and review point.