Treating the Behavioral Symptoms of Dementia

  • Brianne M. NewmanEmail author


Mood and behavior changes are part of the clinical presentation and/or course of the dementias. The treatment of these symptoms is complex, with significant side effects and/or paucity of data limiting evidence-based guidance for the treating physician. Non-pharmacological interventions are first-line treatment for the behavior and psychological symptoms of dementia (BPSD). However, severe mood and behavioral changes often warrant pharmacological intervention requiring detailed risk/benefit analysis regarding medication choice. This chapter focuses on the clinical treatment of BPSD pertinent for the treating neurologist, providing a synopsis of the evidence supporting medication use and practical guidance on treatment selection, monitoring, and discontinuation.


Dementia, behavioral and psychological symptoms of dementia (BPSD) Neuropsychiatric symptoms of dementia Antipsychotic medication and dementia Antidepressant medications and dementia 


  1. 1.
    Steele C, Rovner B, Chase BA, et al. Psychiatric symptoms and nursing home placement of patients with Alzheimer’s disease. Am J Psychiatr. 1990;147:1049–51.CrossRefPubMedGoogle Scholar
  2. 2.
    Balestreri L, Grossberg A, Grossberg GT. Behavioral and psychological symptoms of dementia as a risk factor for nursing home placement. Int Psychogeriatr. 2000;12(Supplement 1):59–62.CrossRefGoogle Scholar
  3. 3.
    Ballard CG, et al. Management of agitation and aggression associated with Alzheimer disease. Nat Rev Neurol. 2009;5(5):245–55.CrossRefPubMedGoogle Scholar
  4. 4.
    Kales H, Gitlin L, Lyketsos C. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. J Am Geriatr Soc. 2014;62:762–9.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Kales H. Common sense: addressed to geriatric psychiatrists on the subject of behavioral and psychological symptoms of dementia. Am J Geriatr Psychiatry. 2015;23:1209–13.CrossRefPubMedGoogle Scholar
  6. 6.
    Tampi RR, Tampi DJ, Balachandran S, Srinivasan S. Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses. Ther Adv Chronic Dis. 2016;7(5):229–45.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Livingston G, Kelly L, Lewis-Holmes E, Baio G, Morris S, Patel N, Omar RZ, Katona C, Cooper C. Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials. Br J Psychiatry. 2014;205(6):436–42.CrossRefPubMedGoogle Scholar
  8. 8.
    Cooke ML, Moyle W, Shum DH, Harrison SD, Murfield JE. A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia. Aging Ment Health. 2010;14:905–16.CrossRefPubMedGoogle Scholar
  9. 9.
    Lin Y, Chu H, Yang CY, Chen CH, Chen SG, Chang HJ, et al. Effectiveness of group music intervention against agitated behavior in elderly persons with dementia. Int J Geriatr Psychiatry. 2011;26:670–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Sung HC, Lee WL, Li TL, Watson R. A group music intervention using percussion instruments with familiar music to reduce anxiety and agitation of institutionalized older adults with dementia. Int J Geriatr Psychiatry. 2012;27:621–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Ballard CG, O’Brien JT, Reichelt K, Perry EK. Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebo-controlled trial with Melissa. J Clin Psychiatry. 2002;63:553–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Burns A, Perry E, Holmes C, Francis P, Morris J, Howes MJ, et al. A double-blind placebo-controlled randomized trial of Melissa officinalis oil and donepezil for the treatment of agitation in Alzheimer’s disease. Dement Geriatr Cogn Disord. 2011;31:158–64.CrossRefPubMedGoogle Scholar
  13. 13.
    Zuidema S, Johansson A, Selbaek G, Murray M, Burns A, Ballard C, et al. A consensus guideline for antipsychotic drug use for dementia in care homes. Bridging the gap between scientific evidence and clinical practice. Int Psychogeriatr. 2015;27:1849–59.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    FDA public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. 2005. Accessed 20 Feb 2017.
  15. 15.
    By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–46.CrossRefGoogle Scholar
  16. 16.
    Schneider L, Pollock V, Lyness S. A meta-analysis of controlled trials of neuroleptic treatment in dementia. J Am Geriatr Soc. 1990;38:553–63.CrossRefPubMedGoogle Scholar
  17. 17.
    Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias. American Psychiatric Association. 2007.Google Scholar
  18. 18.
    Guideline watch (October 2014): practice guideline for the treatment of patients with Alzheimer’s disease and other dementias. American Psychiatric Association. 2014.Google Scholar
  19. 19.
    Declercq T, Petrovic M, Azermai M, Vander SR, De Sutter A, Van Driel M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2013;3:CD007726.Google Scholar
  20. 20.
    Pan Y, Wu C, Gau S, Chan H, Banerjee S. Antipsychotic discontinuation in patients with dementia: a systematic review and meta-analysis of published randomized controlled studies. Dement Geriatr Cogn Disord. 2014;37:125–40.CrossRefPubMedGoogle Scholar
  21. 21.
    Reus VI, Fochtmann LJ, Evan Eyler A, Hilty DM, Horvitz-Lennon M, Jibson MD, Lopez OL, Mahoney J, Pasic J, Tan ZS, Wills CD, Rhoads R, Yager J. The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatr. 2016;173(5):543–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Devanand DP, Mintzer J, Schultz SK, et al. Relapse risk after discontinuation of risperidone in Alzheimer’s disease. N Engl J Med. 2012;367(16):1497–507.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Seitz D, Adunuri N, Gill S, Gruneir A, Herrmann N, Rochon P. Antidepressants for agitation and psychosis in dementia. Cochrane Database Syst Rev. 2011;2:CD008191.Google Scholar
  24. 24.
    Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, et al., CitAD Research Group. Effect of citalopram on agitation in Alzheimer’s disease – the CitAD randomized controlled trial. JAMA: J Am Med Assoc. 2014;311(7):682–91.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    FDA Drug Safety Communication: revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses. Accessed 27 Nov 2017.
  26. 26.
    Birks J. Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database Syst Rev. 2006;(1).Google Scholar
  27. 27.
    McShane R, Areosa Sastre A, Minakaran N. Memantine for dementia. Cochrane Database Syst Rev. 2006;(2).Google Scholar
  28. 28.
    Panza F, Solfrizzi V, Seripa D, Imbimbo B, Santamato A, Lozupone M, et al. Progresses in treating agitation: a major clinical challenge in Alzheimer’s disease. Expert Opin Pharmacother. 2015;16:2581–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Sadock BJ, Kaplan VA. Kaplan and Sadock’s concise textbook of clinical psychiatry. Philadelphia: Lippincott, Williams and Wilkins; 2008.Google Scholar
  30. 30.
    Aarsland D, Perry R, Larsen JP, et al. Neuroleptic sensitivity in Parkinson’s disease and parkinsonian dementias. J Clin Psychiatry. 2005;66(5):633–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Stinton C, McKeith I, Taylor JP, et al. Pharmacological management of Lewy body dementia: a systematic review and meta-analysis. Am J Psychiatry. 2015;172(8):731–42.CrossRefPubMedGoogle Scholar
  32. 32.
    Lochhead JD, Nelson MA, Maguire GA. The treatment of behavioral disturbances and psychosis associated with dementia. Psychiatr Pol. 2016;50(2):311–22.CrossRefPubMedGoogle Scholar
  33. 33.
    Garre-Olmo J, López-Pousa S, Vilata-Franch J, Turon-Estrada A, Hernàndez-Ferràndiz M, Lozano-Gallego M, et al. Evolution of depressive symptoms in Alzheimer’s disease: one-year follow-up. Alzheimer Dis Assoc Disord. 2003;17(2):77–85.CrossRefPubMedGoogle Scholar
  34. 34.
    Zubenko GS, Zubenko WN, McPherson S, Spoor E, Marin DB, Farlow MR, Sunderland T. A collaborative study of the emergence and clinical features of the major depressive syndrome of Alzheimer’s disease. Am J Psychiatr. 2003;160(5):857–66.CrossRefPubMedGoogle Scholar
  35. 35.
    Lyketsos CG, Olin JT. Depression in Alzheimer’s disease: overview and treatment. Biol Psychiatry. 2002;52(3):243–52.CrossRefPubMedGoogle Scholar
  36. 36.
    García-Alberca JM. Cognitive-behavioral treatment for depressed patients with Alzheimer’s disease. An open trial. Arch Gerontol Geriatr. 2017;71:1–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Teri L, Logsdon RG, Uomoto J, McCurry SM. Behavioral treatment of depression in dementia patients: a controlled clinical trial. J Gerontol B Psychol Sci Soc Sci. 1997;52(4):159–66.CrossRefGoogle Scholar
  38. 38.
    Teri L, Gibbons LE, McCurry SM, Logsdon RG, Buchner DM, Barlow WE, et al. Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial. J Am Med Assoc. 2003;290:2015–22.CrossRefGoogle Scholar
  39. 39.
    Woods B, Spector A, Jones C, Orrell M, Davies S. Reminiscence therapy for dementia. Cochrane Database Syst Rev. 2005;18(2):CD001120.Google Scholar
  40. 40.
    Forstmeier S, Maercker A, Savaskan E, Roth T. Cognitive behavioural treatment for mild Alzheimer’s patients and their caregivers (CBTAC): study protocol for a randomized controlled trial. Trials. 2015;16:526.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Nyth AL, Gottfries CG, Lyby K, Smedegaard-Andersen L, Gylding-Sabroe J, Kristensen M, Refsum HE, Ofsti E, Eriksson S, Syversen S. A controlled multicenter clinical study of citalopram and placebo in elderly depressed patients with and without concomitant dementia. Acta Psychiatr Scand. 1992;86:138–45.CrossRefPubMedGoogle Scholar
  42. 42.
    Lyketsos CG, DelCampo L, Steinberg M, Miles Q, Steele CD, Munro C, Baker AS, Sheppard JM, Frangakis C, Brandt J, Rabins PV. Treating depression in Alzheimer disease: efficacy and safety of sertraline therapy, and the benefits of depression reduction: the DIADS. Arch Gen Psychiatry. 2003;60:737–46.CrossRefPubMedGoogle Scholar
  43. 43.
    Rabins P, Rovner BW, Rummans T, et al. Guideline watch (October 2014): practice guideline for the treatment of patients with Alzheimer’s disease and other dementias. Am J Psychiatry. 2007 Dec;164(12 Suppl):5–56.PubMedGoogle Scholar
  44. 44.
    Galynker I, Ieronimo C, Miner C, Rosenblum J, Vilkas N, Rosenthal R. Methylphenidate treatment of negative symptoms in patients with dementia. J Neuropsychiatry Clin Neurosci. 1997;9:231–9.CrossRefPubMedGoogle Scholar
  45. 45.
    Rosenberg PB, Lanctôt KL, Drye LT, Herrmann N, Scherer RW, Bachman DL, Mintzer JE. ADMET Investigators: safety and efficacy of methylphenidate for apathy in Alzheimer’s disease: a randomized, placebo-controlled trial. J Clin Psychiatry. 2013;74(8):810–6.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Frakey LL, Salloway S, Buelow M, Malloy P. A randomized, double-blind, placebo-controlled trial of modafinil for the treatment of apathy in individuals with mild-to-moderate Alzheimer’s disease. J Clin Psychiatry. 2012;73(6):796–801.CrossRefPubMedGoogle Scholar
  47. 47.
    Tew JD Jr, Mulsant BH, Haskett RF, Prudic J, Thase ME, Crowe RR, Dolata D, Begley AE, Reynolds CF III, Sackeim HA. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry. 1999;156:1865–70.PubMedGoogle Scholar
  48. 48.
    Rao V, Lyketsos CG. The benefits and risks of ECT for patients with primary dementia who also suffer from depression. Int J Geriatr Psychiatry. 2000;15:729–35.CrossRefPubMedGoogle Scholar
  49. 49.
    O’Connor MK, Knapp R, Husain M, Rummans TA, Petrides G, Smith G, Mueller M, Snyder K, Bernstein H, Rush AJ, Fink M, Kellner C. The influence of age on the response of major depression to electroconvulsive therapy: a C.O.R.E. report. Am J Geriatr Psychiatry. 2001;9:382–90.CrossRefPubMedGoogle Scholar
  50. 50.
    Thapa PB, Gideon P, Cost TW, Milam AB, Ray WA. Antidepressants and the risk of falls among nursing home residents. N Engl J Med. 1998;339:875–82.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Adult Psychiatry Training Program, Department of Psychiatry and Behavioral NeuroscienceSaint Louis University School of MedicineSt. LouisUSA

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