Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Behavioural and psychological symptoms of dementia
Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Acute behaviour change may signal dangerous illness
Sudden agitation, withdrawal, hallucinations, reduced intake or altered arousal with hypoxia, infection, pain, retention, constipation, hypoglycaemia, injury, stroke signs, seizure or medicine toxicity requires urgent medical and delirium assessment rather than behavioural containment.
Action: Assess ABCDE, glucose, observations, attention and focal neurology; obtain baseline and onset; address pain, toileting and sensory needs; review medicines; and treat likely causes in parallel. Use calm one-person communication and proportionate observation, escalating emergency medical or mental-health support for immediate harm risk.
Overview
Interpret distress and behaviour as communication, identify delirium and remediable clinical or environmental causes, deliver personalised psychosocial care, and restrict antipsychotics to NICE-defined severe distress or harm-risk situations.
Behavioural and psychological symptoms of dementia is an umbrella description for experiences such as anxiety, low mood, apathy, irritability, agitation, aggression, sleep reversal, wandering, calling out, hallucinations and delusions. Each has multiple possible meanings. A person repeatedly attempting to leave may be seeking a familiar role, responding to noise, needing the toilet, experiencing pain or developing delirium. Replace a global label with an observable description, time course, severity, distress, harm and context.
Sudden change is a medical problem first. Establish hours, days or weeks of onset against baseline and assess attention and arousal. Hypoxia, infection, dehydration, hypoglycaemia, constipation, urinary retention, pain, injury, organ failure, intoxication, withdrawal and medicine toxicity may appear as agitation or withdrawal. A positive urine dipstick alone does not explain distress in an older person. Examine and investigate according to clinical findings while providing supportive delirium care.
Practice
Two practice questions
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Question 1 of 2
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PsychiatryOriginal SBA
Initial distress response
A care-home resident with dementia begins shouting during evening personal care. Observations are stable and there is no immediate harm risk. What is the best initial management approach under NICE guidance?
Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE NG97 dementia recommendationsStructured cause assessment, psychosocial care, strict antipsychotic thresholds, six-week review, stopping, activities and valproate advice.
NICE antipsychotic decision aidShared decision support covering possible benefit, common adverse effects and increased stroke and mortality risk.
Risperidone 0.5 mg SmPCCurrent UK licensed indication, dose titration, maximum, six-week limit and safety information for Alzheimer's aggression.
NICE CG103 delirium recommendationsRecognition and management of acute fluctuating change that may present as altered behaviour in dementia.
NICE recommends structured assessment before either non-pharmacological or pharmacological treatment. Map antecedent, behaviour and consequence across different staff, times and settings. Ask what communication was attempted, whether glasses or hearing aids worked, whether personal care was rushed, and whether the environment was crowded, dark, hot or unfamiliar. Review sleep, hunger, thirst, intimacy, loneliness, trauma, culture, routine and meaningful activity. Speak with the person and chosen supporters rather than relying solely on service descriptions.
Communication is intervention. Approach within the person's visual field, introduce yourself, use one idea at a time and allow enough processing time. Validate emotion without confirming a false belief, offer simple choices and withdraw when care can safely wait. Avoid arguing about facts, crowding, repeated commands and sudden touch. Adapt personal care to preferred gender, sequence and privacy. A life-history account can explain why uniforms, bathing, alarms or entering a bedroom provoke fear.
Psychosocial and environmental measures remain initial and ongoing care. Correct pain and sensory barriers, establish predictable routines, support daytime activity and sleep cues, reduce unnecessary noise and moves, and offer familiar objects and people. NICE specifically recommends personalised activities for agitation or aggression to promote engagement, pleasure and interest. Music, exercise, reminiscence, occupational tasks or outdoor access need individual evaluation; an activity that calms one person may overwhelm another.
Risk formulation distinguishes distress from inconvenience. Walking is not automatically dangerous; assess route, traffic, weather, footwear, falls and whether accompanied access can preserve freedom. Calling out may disturb a ward yet express fear or pain. Restriction, seclusion and restraint can intensify trauma, delirium and injury and must be lawful, necessary, proportionate and least restrictive. Increased observation should include hydration, comfort, toileting, orientation and reassessment rather than surveillance alone.
NICE limits antipsychotic use to people at risk of harming themselves or others, or those with agitation, hallucinations or delusions causing severe distress. Before prescribing, discuss likely modest benefit and serious harms, including sedation, falls, extrapyramidal effects, stroke and increased mortality. Lewy-body and Parkinson's disease dementia can produce severe sensitivity. Check indication, target symptom, baseline observations, cardiovascular and neurological risk, interactions and a planned review and stop date.
Use the lowest effective dose for the shortest possible time and reassess at least every six weeks. Stop if there is no clear ongoing benefit after discussion with the person and family or carers as appropriate. Risperidone has a specific UK marketing authorisation only for persistent aggression in moderate-to-severe Alzheimer's dementia, unresponsive to non-drug approaches and with harm risk, for up to six weeks. Other uses may be off-label and require explicit, well-informed prescribing governance. Haloperidol also has a narrow authorisation and substantial neurological and cardiac cautions.
Valproate should not be offered to manage agitation or aggression in dementia unless prescribed for another condition. Benzodiazepines can worsen sedation, falls, disinhibition and delirium and are not a routine behavioural solution. Review existing medicines for anticholinergic load, akathisia, hypotension, constipation, withdrawal or sleep disruption. Continue psychosocial and environmental interventions while an antipsychotic is used and after it is stopped; medication never removes the obligation to address causes.
Measure outcomes that matter: frequency and intensity of the specified behaviour, subjective distress, injury, sleep, mobility, engagement and carer impact, alongside adverse effects. Record the formulation and strategies that work so they transfer across settings. Recurrent or escalating symptoms justify renewed assessment, not automatic represcribing. Support carers with education, respite and crisis planning, and raise safeguarding concerns when neglect, fear, coercion or excessive restriction may be contributing.
Key points
Agitation, aggression, calling out, wandering, resistance, apathy, sleep change, hallucinations, delusions and anxiety are descriptions requiring formulation, not diagnoses to suppress.
Define exactly what happens, when, with whom and what precedes and follows it; vague labels such as challenging conceal useful triggers.
NICE requires structured assessment for pain, delirium, inappropriate care and other clinical or environmental reasons before treatment for distress.
Offer psychosocial and environmental interventions as initial and ongoing management, matched to communication, history, culture, sensory ability and preferences.
Personalised activities should promote engagement, pleasure and interest for agitation or aggression rather than merely occupy time.
Only offer an antipsychotic when the person risks harming themselves or others, or agitation, hallucinations or delusions cause severe distress.
Discuss benefits and harms, use the lowest effective dose for the shortest possible time, reassess at least every six weeks and stop without clear ongoing benefit.
Risperidone's UK licence is narrow: up to six weeks for persistent aggression in moderate-to-severe Alzheimer's disease after non-drug approaches and with harm risk.
Do not offer valproate for agitation or aggression in dementia unless it is indicated for another condition.
Aetiology
01
Unmet physical need
Pain, infection, constipation, urinary retention, dehydration, hunger, sensory loss and medication effects can appear as agitation, withdrawal or resistance.
02
Environmental mismatch
Noise, crowding, poor lighting, unfamiliar routines, rushed care and inaccessible communication can overwhelm reduced cognitive processing capacity.
03
Neuropsychiatric disease
Dementia pathology alters perception, salience, inhibition, sleep and emotional regulation, while depression, psychosis and delirium may coexist.
04
Relational and biographical triggers
Trauma, identity, prior occupation, attachment and the manner of care shape how a person interprets touch, separation and restriction.
Pathophysiology
1
Reduced threat discrimination
Impaired memory and contextual processing can make unfamiliar people or care actions feel dangerous despite benign intention.
2
Executive control loss
Frontal network dysfunction reduces inhibition, flexibility and the ability to express a need through planned language or problem solving.
3
Perceptual instability
Visual, attentional and sensory processing disturbances promote misidentification and hallucinations, particularly in Lewy-body disease and delirium.
4
Stress arousal cycle
Fearful care interactions increase physiological arousal, which further reduces comprehension and creates escalating reciprocal emotional distress.
Clinical features and red flags
Agitation and aggression
Restlessness, shouting, striking, pushing or resistance may communicate fear, pain, intrusion, frustration or an acute physiological disturbance.
Psychotic experiences
Hallucinations, misidentification and fixed beliefs require assessment of sensory loss, delirium, Lewy-body disease, medicines and actual distress.
Apathy and withdrawal
Reduced initiative and engagement can reflect dementia, depression, hypoactive delirium, oversedation, pain or an inaccessible environment.
Wandering or exit seeking
Purposeful movement, occupational memory, anxiety, unmet needs and disorientation can underlie walking that others experience as disruptive.
Sleep-wake disruption
Night waking and daytime sleepiness may relate to pain, environment, sleep disorder, inactivity, medicines or delirium rather than intentional disturbance.
Care-related resistance
Refusal during washing, dressing or medication may arise from impaired comprehension, loss of privacy, trauma, rushed care or decision-specific disagreement.
Red flags requiring action
Hours-to-days fluctuation in attention or arousal is delirium superimposed on dementia until acute causes have been assessed and treated.
New focal neurology, seizure, head injury, severe headache, reduced consciousness or abnormal physiology needs an emergency medical pathway.
Investigations
01ABC description and timelineFirst step
Why
Record antecedents, observable behaviour, consequences, onset, fluctuation, frequency, severity and setting.
Interpretation and limitations
Repeating patterns can identify remediable triggers and distinguish chronic distress from a new delirium syndrome.
2Describe antecedents, behaviour and consequences and ask the person and supporters about communication, routine and likely meaning.
3Treat clinical causes and implement personalised communication, environmental and activity measures with a named review point.
02Persistent symptomsPersonalise psychosocial careDistress continues after acute causes have been addressed and no immediate severe harm threshold dominates.+
1Agree a formulation linking triggers, unmet needs, strengths, preferences, life history, sensory ability and environmental barriers.
2
Complications
01
Injury and crisis admission
Untreated distress, falls, conflict and restrictive responses can culminate in trauma, emergency transfer and further delirium.
02
Antipsychotic harm
Sedation, falls, extrapyramidal effects, stroke and increased mortality may outweigh modest symptom benefit, especially without review.
03
Relationship breakdown
Repeated fear and misinterpretation can exhaust carers and damage trust when support and respite are unavailable.
04
Loss of liberty
Risk-averse restriction may remove movement, meaningful activity and autonomy beyond what safety and capacity law justify.
05
Missed medical illness
Attributing acute change to dementia delays treatment of infection, pain, retention, metabolic disturbance or neurological disease.
Monitoring and follow-up
Track the specifically defined target behaviour, its trigger, distress, harm, frequency and effect on meaningful activity rather than a global behaviour score alone.
Repeat pain, delirium, bowel, bladder, hydration, sleep, sensory and medication assessment whenever symptoms change or recur.
During antipsychotic treatment monitor alertness, gait, falls, blood pressure, extrapyramidal signs, swallowing, cardiovascular events and target benefit.
Reassess antipsychotic need at least every six weeks and stop if clear ongoing benefit is absent after appropriate discussion.
Review restriction and observation for necessity, proportionality, legal authority and whether a less restrictive alternative is now possible.
Document successful communication and environmental strategies in a portable care plan and update carers and receiving services with consent.
Special situations
Behaviour has context
Variation by carer, time or setting is clinically useful evidence about communication, environment and unmet need rather than proof of manipulation.
Quiet can be dangerous
Withdrawal and reduced movement may reflect hypoactive delirium or oversedation even though they create less disruption for a service.
Walking can express purpose
Understanding a person's former work, routines and destination can turn indiscriminate restriction into supported, safer movement.
Sedation is not benefit
A quieter person may still be frightened or in pain, so outcome review must include distress, engagement, mobility and adverse effects.
The formulation travels
Recording triggers, meanings and effective responses prevents each new ward or care team from restarting with restrictive trial and error.
Common pitfalls
01
Calling behaviour challenging without documenting what happened, its timing, antecedents, meaning, distress and consequences.
02
Prescribing for an acute behaviour change before assessing delirium, pain, retention, constipation, injury and medicine effects.
03
Treating staff disruption as equivalent to severe distress or risk of harm under NICE antipsychotic criteria.
04
Using sedation as the outcome measure while mobility, swallowing, engagement and subjective fear worsen.
05
Continuing an antipsychotic without a target, benefit record, at-least-six-weekly reassessment or stop plan.
06
Offering valproate for agitation or aggression in dementia when there is no other clinical indication.
07
Ignoring severe antipsychotic sensitivity risk in Lewy-body or Parkinson's disease dementia.
08
Stopping psychosocial and environmental work after medication begins or failing to preserve successful strategies across transfers.
Continue psychosocial care during and after medication; sedation is not evidence that fear, pain, boredom or unmet need has resolved.
Pain, urinary retention, faecal impaction, dehydration, hunger, infection and medicine withdrawal can present primarily as distress or aggression.
Immediate risk of serious harm to the person or others requires a least-restrictive safety response while causes are investigated.
Rigidity, fever, dysphagia, marked sedation or autonomic instability after an antipsychotic requires urgent cessation and medical assessment.
Dementia with Lewy bodies or Parkinson's disease dementia increases the risk of severe antipsychotic sensitivity and motor deterioration.
Unexplained fear of a particular person, bruising, restraint, poor hygiene, malnutrition or financial control raises a safeguarding concern.
Why
Define distress, harm, frequency, function and carer impact before any time-limited intervention.
Interpretation and limitations
A measurable target allows meaningful benefit review and prevents sedation from being mistaken for recovery.
06Antipsychotic safety assessment
Why
Review cardiovascular, cerebrovascular, neurological, falls, metabolic and interaction risks when strict criteria are met.
Interpretation and limitations
Possible Lewy-body disease, parkinsonism, QT risk or prior sensitivity may make usual antipsychotic choices unsafe.
Offer tailored activities, pain and sleep care, communication adaptations, mobility and carer support while avoiding unnecessary restriction.
3Measure distress, engagement, function and adverse events and revise the formulation when an intervention does not help.
03Exceptional medicine usePrescribe against a target and stop planThere is harm risk or agitation, hallucinations or delusions cause severe distress despite structured assessment and appropriate non-drug care.+
1Discuss benefits, stroke, mortality, sedation, falls and neurological harms and identify subtype, contraindications, target symptom and baseline.
2Use the lowest effective dose for the shortest possible time while continuing clinical, psychosocial and environmental interventions.
3Reassess at least every six weeks and stop when clear ongoing benefit is absent, documenting discussion and any safer continuing plan.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
A narrowly licensed adjunct for persistent aggression in moderate-to-severe Alzheimer's dementia after non-pharmacological approaches have failed and harm risk exists.
Risperidone for licensed persistent aggression in Alzheimer's dementia
Start 0.25 mg by mouth twice daily; if required increase by 0.25 mg twice daily no more often than every other day; usual 0.5 mg twice daily, maximum 1 mg twice daily, for no longer than 6 weeks.
Use only after individual benefit-harm discussion; monitor sedation, orthostatic hypotension, falls, extrapyramidal effects and cerebrovascular risk; reduce and titrate more slowly in renal or hepatic impairment, and avoid reflex use in Lewy-body or Parkinson's disease dementia.