Behavioral & Psychiatric Symptoms of Dementia

Hallucinations, behavioral changes, paranoid delusions, and long periods of screaming were described by Alzheimer in 1907 in his original case description of the disease.
Behavioral and psychological symptoms of dementia (BPSD) are an integral part of dementia syndrome. A gradual downfall in emotional control or motivation, or a change in social behavior manifesting as emotional lability, irritability, apathy and coarsening of social behavior have been a part of diagnostic criteria for dementia. Studies suggest that cognition and behavior are independent dimensions. However, they influence each other; BPSD is associated with a more rapid rate of cognitive decline and greater impairment in activities of daily living; and there are variations in severity of BPSD at different cognitive levels.

BPSD are often the reasons for the first contact with health professionals and hospitalization. BPSD impact patient functioning and lead to premature transition to structured living environments and institutionalization. They are a cause of concern and burden to the caregivers; and are often more difficult to cope with than cognitive changes. These symptoms are a major cause of diminished quality of life for both patients and care givers. BPSD contribute significantly to the overall costs of dementia care.

These noncognitive abnormalities which increase the morbidity of patients and burden of caregivers are mostly treatable. Their assessment and management are essential components of the treatment of dementia. Periodic assessment of these symptoms can measure the effectiveness of interventions in dementia. This review aims to study the features of BPSD, their assessment and management. Literature of BPSD was searched in PUBMED and the relevant cross references were accessed.


Various theoretical models have been proposed to understand BPSD which basically guide the non-pharmacological intervention. They are: ‘unmet needs’ model, a behavioral/learning model, and an environmental vulnerability/reduced stress-threshold model. Often the needs are not apparent to the observer or the caregiver, or the caregivers do not feel able to fulfill these needs. The needs namely biological, social and psychological lead to discomfort and the distress, and in a background of impaired cognitive state and ineffective communication, these often manifest as BPSD.
Many problem behaviors are learned through reinforcement by caregivers or staff members, who provide attention when problem behavior is displayed.

The arousal of BPSD is possibly from the intensive approach to care where patients are stressed beyond their cognitive capabilities. It is assumed that dementia process results in greater vulnerability to the environment, and a lower threshold at which stimuli affects behavior. Individuals suffering from dementia progressively lose their coping abilities and therefore perceive their environment as more and more stressful, which results in anxiety and inappropriate behavior.

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