Major Neurocognitive Disorder with Behavioral Disturbance (Behavioral and Psychological Symptoms of Dementia—BPSD)

  • Christopher O’Connell
  • Howard H. FennEmail author
  • Rita Hitching


DSM-5 specifies major neurocognitive disorder (MNCD) as “with” or “without” behavioral disturbance. According to the Alzheimer’s Disease International: World Alzheimer Report 2014 (World Alzheimer Report 2014), 98% of people with MNCD will experience non-cognitive, or behavioral, symptoms at some point in their illness. These behavioral and psychological symptoms of dementia (BPSD) can include depression, anxiety, apathy, agitation, wandering, aggressive behavior, repetitive complaints, obsessive-compulsive behaviors, delusions, hallucinations, and disordered sleep.

The non-cognitive symptoms (NCS) and neuropsychiatric symptoms (NPS), which often accompany MNCD, can disrupt living situations and delivery of medical treatment. As a result, they are likely to precipitate placement out of the home or exclusion from a long-term living situation. Psychiatric inpatient hospitalization or admission to a similar unit may be the result. Management of BPSD is also crucial because both patient and others in the facility may be at risk of injury and/or assault. This chapter reviews the phenomenology and diagnosis of BPSD, as well as treatment and management options in the inpatient setting.


Non-cognitive symptoms Major neurocognitive disorder BPSD Agitation Behavioral disturbance 


  1. 1.
    McCarthy JFBF, Kales HC. Disruptive behaviors in veterans affairs nursing home residents: how different are residents with serious mental illness? J Am Geriatr Soc. 2004;52(12):2031–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Nowrangi MA, Lyketsos CG, Rosenberg PB. Principles and management of neuropsychiatric symptoms in Alzheimer’s dementia. Alzheimers Res Ther. 2015;7(1):12. Scholar
  3. 3.
    Centers for Medicare & Medicaid Services. National partnership to improve dementia care in nursing homes. 2017.
  4. 4.
    Vaportzis E, Mike Martin M, Gow AJ. A tablet for healthy ageing: the effect of a tablet computer training intervention on cognitive abilities in older adults. Am J Geriatr Psychiatry. 2017;25(8):841–51.PubMedCrossRefGoogle Scholar
  5. 5.
    Vahia I, Kamat R, Vang C, Posada C, Lisa Ross L, Oreck S, Bhatt A, Depp C, Jeste DV, Daniel D, Sewell DD. Use of tablet devices in the management of agitation among inpatients with dementia: an open-label study. Am J Geriatr Psychiatry. 2017;25(8):860–4.PubMedCrossRefGoogle Scholar
  6. 6.
    Cummings J, et al. Agitation in cognitive disorders: international psychogeriatric association provisional consensus clinician and research definition. Int Psychogeriatr. 2015a;27(1):7–17.PubMedCrossRefGoogle Scholar
  7. 7.
    Cummings JL, Lyketsos CG, Peskind ER, Porsteinsson AP, Mintzer JE, Scharre DW, et al. Effect of dextromethorphan-quinidine on agitation in patients with Alzheimer disease dementia: a randomized clinical trial. JAMA. 2015b;314(12):1242–54. Scholar
  8. 8.
    Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA. 2005;293(5):596–608. Scholar
  9. 9.
    Peisah C, Strukovski JA, Wijeratne C, Mulholland R, Luscombe G, Brodaty H. The development and testing of the quality use of medications in dementia (QUM-D): a tool for quality prescribing for behavioral and psychological symptoms of dementia (BPSD). Int Psychogeriatr. 2015;27(8):1313–22. . C International Psychogeriatric Association 2015. This is an Open Access article, distributed under the terms of the Creative Commons Attribution license (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. Scholar
  10. 10.
    Cohen-Mansfield J, Marx M, Rosenthal A. A description of agitation in a nursing home. J Gerontol. 1989;44:M77–84.PubMedCrossRefGoogle Scholar
  11. 11.
    Cummings JL, et al. The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology. 1994;44:2308–14.CrossRefGoogle Scholar
  12. 12.
    Reisberg B, Monteiro I, Torossian C, Auer S, Shulman MB, Ghimire S, Boksay I, GuilloBenArous F, Osorio R, Vengassery A, Imran S, Shaker H, Noor S, Naqvi S, Kenowsky S, Xu J. The Behave-Ad assessment system: a perspective, a commentary on new findings, and a historical review. Dement Geriatr Cogn Disord. 2014;38(1–2):89–146. Epub 2014 Apr 7.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Nelson L, Tabet N. Slowing the progression of Alzheimer’s disease; what works? Ageing Res Rev. 2015;23(Pt B):193–209. Scholar
  14. 14.
    Maldonado J. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin. 2008;24:657–722.PubMedCrossRefGoogle Scholar
  15. 15.
    Oldham MA, Flaherty JH, Maldonado JR. Refining delirium: a transtheoretical model of delirium disorder with preliminary neurophysiologic subtypes. Am J Geriatr Psychiatry. 2018;26(9):913–24.CrossRefGoogle Scholar
  16. 16.
    Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–9. PubMedCrossRefGoogle Scholar
  17. 17.
    Inouye S, van Dyck C, Alessi C, Balkin S, Siegal A, Horwitz R. Clarifying confusion: the confusion assessment method. Ann Intern Med. 1990;113(12):941–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Cole MMM, Voyer P, Monette J, Champoux N, Ciampi A, Vu M, Dyachenko A, Belzile E. Symptoms of delirium occurring before and after episodes of delirium in older long-term care residents. J Am Geriatr Soc. 2012;60(12):2302–7. Epub 2012 Nov 29PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    De J, Wand AP, Smerdely PI, Hunt GE. Validating the 4A’s test in screening for delirium in a culturally diverse geriatric inpatient population. Int J Geriatr Psychiatry. 2017;32(12):1322–9. Epub 2016 Oct 20PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Gleason LJ, Schmitt EM, Kosar CM, Tabloski P, Saczynski JS, Robinson T, Cooper Z, Rogers SO Jr, Jones RN, Marcantonio ER, Inouye SK. Effect of delirium and other major complications on outcomes after elective surgery in older adults. JAMA Surg. 2015;150(12):1134–40. Scholar
  21. 21.
    Zenilman M. Delirium: an important postoperative complication. JAMA. 2017;317(12):77–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Fong TG, Inouye SK, Jones RN. Delirium, dementia, and decline. JAMA Psychiatry. 2017, 2017;(online):E1–2. Published online January 18Google Scholar
  23. 23.
    Jaidi Y, Nonnonhou V, Kanagaratnam L, Bertholon LA, Badr S, Noel V, J-l N, Mahmoudi R. Reduction of the anticholinergic burden makes it possible to decrease behavioral and psychological symptoms of dementia. Am J Geriatr Psychiatry. 2018;26:280–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Tosato M, Lukas A, van der Roest HG, Danese R, Antocicco M, Finne-Soveri H, Nikolaus T, Landi F, Bernabei R, Onder G. Association of pain with behavioral and psychiatric symptoms among nursing home residents with cognitive impairment: results from the SHELTER study. Pain. 2012;153:305–10.PubMedCrossRefGoogle Scholar
  25. 25.
    Husebo BS, Ballard C, Cohen-Mansfield J, Seifert R, Aarsland D. The response of agitated behavior to pain management in persons with dementia. Am J Geriatr Psychiatry. 2014;22(7):708–17.PubMedCrossRefGoogle Scholar
  26. 26.
    Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioral disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ. 2011:343. Scholar
  27. 27.
    Hadijstavropoulos T, Herr K, Prkachin KM, Craig KD, Gibson SJ, Lukas A, Smith JH. Pain assessment in elderly adults with dementia, Vol 13, December 2014.
  28. 28.
    Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) demean scale. J Am Med Dir Assoc. 2003;4:9–15.PubMedCrossRefGoogle Scholar
  29. 29.
    Ammaturo DA, Hadjistavropoulos T, Williams J. Pain in dementia: use of observational pain assessment tools by people who are not health professionals. Pain Med. 2016;18(10):1895–907. Scholar
  30. 30.
    Husebo BS, Strand LI, Moe-Nilssen R, Husebo SB, Ljunggren AE. Pain behaviour and pain intensity in older persons with severe dementia: reliability of the MOBID Pain Scale by video uptake. Scand J Caring Sci. 2009;23(1):180–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Husebo BS, Achterberg W, Flo E. Identifying and managing pain in people with Alzheimer’s disease and other types of dementia: a systematic review. CNS Drugs. 2016;30:481–97. Scholar
  32. 32.
    Makris U, Abrams RC, Gurland B, Reid CM. Management of persistent pain in the older patient: a clinical review. JAMA. 2014;312(8):825–36. Scholar
  33. 33.
    Rohner JD, Warren JD. Phenomenology and anatomy of abnormal behaviors in primary progressive aphasia. J Neurol Sci. 2010;293:35–8. [3]CrossRefGoogle Scholar
  34. 34.
    Fortier-Brochu É, Morin CM. Cognitive impairment in individuals with insomnia: clinical significance and correlates. Sleep. 2014;37(11):1787–98. Scholar
  35. 35.
    Rose KM, Beck C, Tsai PF, Liem PH, Davila DG, Kleban M, Gooneratne NS, Kalra G, Richards KC. Sleep disturbances and nocturnal agitation behaviors in older adults with dementia. Sleep. 2011;34(6):779–86.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Suzuki K, Miyamoto M, Hirata K. Sleep disorders in the elderly: diagnosis and management. J Gen Fam Med. 2017;8(2):61–71.CrossRefGoogle Scholar
  37. 37.
    Khot SP, Davis AP, Crane DA, et al. Effect of continuous positive airway pressure on stroke rehabilitation: a pilot randomized sham-controlled trial. J Clin Sleep Med. 2016;12:1019.PubMedCrossRefGoogle Scholar
  38. 38.
    Carvalho DZ, St Louis EK, Boeve BF, Mielke MM, Przybelski SA, Knopman DS, Machulda MM, Roberts RO, Geda YE, Petersen RC, Jack CR Jr, Vemuri P. Excessive daytime sleepiness and fatigue may indicate accelerated brain aging in cognitively normal late middle-aged and older adults. Sleep Med. 2017;32:236–43. Epub 2016 Nov 3PubMedCrossRefGoogle Scholar
  39. 39.
    Ohayon MM, Roth T. Prevalence of restless legs syndrome and periodic limb movement disorder in the general population. J Psychosom Res. 2002;53:547–54.PubMedCrossRefGoogle Scholar
  40. 40.
    Alzheimer’s Disease International: World Alzheimer Report 2014, London, 2014. Available at
  41. 41.
    Gitlin LN, Kales HC, Lyketsos CG. Managing behavioral symptoms in dementia using nonpharmcologic approaches: an overview. JAMA. 2012;308(19):2020–9. Scholar
  42. 42.
    Kales HC, Gitlin LN, Lyketsos CG, Detroit Expert Panel on Assessment and Management of Neuropsychiatric Symptoms of Dementia. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. J Am Geriatr Soc. 2014;62(4):762–9. Scholar
  43. 43.
    Reus VI, Fochtmann LJ, Eyler AE, Hilty DM, Horvitz-Lennon M, Jibson MD, et al. The American psychiatric association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543–6. Scholar
  44. 44.
    American Psychiatric Association. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia. 2016.Google Scholar
  45. 45.
    Yohanna D, Cifu AS. Antipsychotics to treat agitation or psychosis in patients with dementia. JAMA. 2017;318(11):1057–8. Scholar
  46. 46.
    Lonergan E, Luxenberg J, Colford J. Haloperidol for agitation in dementia. Cochrane Database Syst Rev. 2002;2:CD002852.Google Scholar
  47. 47.
    Kales HC, Valenstein M, Kim HM, McCarthy JF, Ganoczy D, Cunningham F, Blow FC. Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric medications. Am J Psychiatry. 2007;164(10):1568–76.; ; quiz 1623. Scholar
  48. 48.
    Maust DT, Kim HM, Seyfried LS, Chiang C, Kavanagh J, Schneider LS, Kales HC. Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm. JAMA Psychiatry. 2015;72(5):438–45. Scholar
  49. 49.
    Huybrechts KF, Gerhard T, Crystal S, Olfson M, Avorn J, Levin R, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012;344:e977. Scholar
  50. 50.
    Gurevich A, Guller V, Berner YN, Tal S. Are atypical antipsychotics safer than typical antipsychotics for treating behavioral and psychological symptoms of dementia? J Nutr Health Aging. 2012;16(6):557–61.PubMedCrossRefGoogle Scholar
  51. 51.
    Mailman RB, Murthy V. Third generation antipsychotic drugs: partial agonism or receptor functional selectivity? Curr Pharm Des. 2010;16(5):488–501.PubMedCrossRefGoogle Scholar
  52. 52.
    Maglione M, Ruelaz M, Hu J, Wang Z, Shanman R, Shekelle P, et al. Off-label use of atypical antipsychotics: an update. Comparative Effectiveness Review No. 43. 2011. Retrieved from
  53. 53.
    Maher A, Theodore G. Summary of the comparative effectiveness review on off-label use of atypical antipsychotics. J Manag Care Pharm. 2012;18(5-b):S1–20.PubMedGoogle Scholar
  54. 54.
    Sultzer DL, Davis SM, Tariot PN, Dagerman KS, Lebowitz BD, Lyketsos CG, et al. Clinical symptom responses to atypical antipsychotic medications in Alzheimer’s disease: phase 1 outcomes from the CATIE-AD effectiveness trial. Am J Psychiatry. 2008;165(7):844–54. Scholar
  55. 55.
    Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14(3):191–210. Scholar
  56. 56.
    Zhong K, Tariot P, Mintzer J, Minkwitz M, Devine N. Quetiapine to treat agitation in dementia: a randomized, double-blind, placebo-controlled study. Curr Alzheimer Res. 2007;4(1):81–93. Scholar
  57. 57.
    Douglas IJ, Smeeth L. Exposure to antipsychotics and risk of stroke: self controlled case series study. BMJ. 2008;337:a1227. Scholar
  58. 58.
    Wu CS, Wang SC, Gau SS, Tsai HJ, Cheng YC. Association of stroke with the receptor-binding profiles of antipsychotics-a case-crossover study. Biol Psychiatry. 2013;73(5):414–21. Scholar
  59. 59.
    Narang P, El-Refai M, Parlapalli R, Danilov L, Manda S, Kaur G, Lippmann S. Antipsychotic drugs: sudden cardiac death among elderly patients. Psychiatry (Edgmont). 2010;7(10):25–9.Google Scholar
  60. 60.
    Wang PS, Schneeweiss S, Avorn J, Fischer MA, Mogun H, Solomon DH, Brookhart MA. Risk of death in elderly users of conventional vs. atypical antipsychotic medications. N Engl J Med. 2005;353(22):2335–41. Scholar
  61. 61.
    Trifiro G, Gambassi G, Sen EF, Caputi AP, Bagnardi V, Brea J, Sturkenboom MC. Association of community-acquired pneumonia with antipsychotic drug use in elderly patients: a nested case-control study. Ann Intern Med. 2010;152(7):418–25., , W139-440. Scholar
  62. 62.
    Fraser LA, Liu K, Naylor KL, Hwang YJ, Dixon SN, Shariff SZ, Garg AX. Falls and fractures with atypical antipsychotic medication use: a population-based cohort study. JAMA Intern Med. 2015;175(3):450–2. Scholar
  63. 63.
    Vigen CL, Mack WJ, Keefe RS, Sano M, Sultzer DL, Stroup TS, et al. Cognitive effects of atypical antipsychotic medications in patients with Alzheimer’s disease: outcomes from CATIE-AD. Am J Psychiatry. 2011;168(8):831–9. Scholar
  64. 64.
    Steinberg M, Lyketsos CG. Atypical antipsychotic use in patients with dementia: managing safety concerns. Am J Psychiatry. 2012;169(9):900–6. Scholar
  65. 65.
    Rossom RC, Rector TS, Lederle FA, Dysken MW. Are all commonly prescribed antipsychotics associated with greater mortality in elderly male veterans with dementia? J Am Geriatr Soc. 2010;58(6):1027–34. Scholar
  66. 66.
    Gerhard T, Huybrechts K, Olfson M, Schneeweiss S, Bobo WV, Doraiswamy PM, et al. Comparative mortality risks of antipsychotic medications in community-dwelling older adults. Br J Psychiatry. 2014;205(1):44–51. Scholar
  67. 67.
    Ballard C, Hanney ML, Theodoulou M, Douglas S, McShane R, Kossakowski K, et al. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. Lancet Neurol. 2009;8(2):151–7. Scholar
  68. 68.
    Devanand DP, Mintzer J, Schultz SK, Andrews HF, Sultzer DL, de la Pena D, et al. Relapse risk after discontinuation of risperidone in Alzheimer’s disease. N Engl J Med. 2012;367(16):1497–507. Scholar
  69. 69.
    Patel AN, Lee S, Andrews HF, Pelton GH, Schultz SK, Sultzer DL, et al. Prediction of relapse after discontinuation of antipsychotic treatment in Alzheimer’s disease: the role of hallucinations. Am J Psychiatry. 2017;174(4):362–9. Scholar
  70. 70.
    Seitz DP, Gill SS, Herrmann N, Brisbin S, Rapoport MJ, Rines J, et al. Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review. Int Psychogeriatr. 2013;25(2):185–203. Scholar
  71. 71.
    Ballard C, Orrell M, YongZhong S, Moniz-Cook E, Stafford J, Whittaker R, et al. Impact of antipsychotic review and nonpharmacological intervention on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia living in nursing homes: a factorial cluster-randomized controlled trial by the well-being and health for people with dementia (WHELD) program. Am J Psychiatry. 2016;173(3):252–62. Scholar
  72. 72.
    Seitz DP, Adunuri N, Gill SS, Gruneir A, Herrmann N, Rochon P. Antidepressants for agitation and psychosis in dementia. Cochrane Database Syst Rev. 2011;2:CD008191. Scholar
  73. 73.
    Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, et al. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. JAMA. 2014;311(7):682–91. Scholar
  74. 74.
    Leonpacher AK, Peters ME, Drye LT, Makino KM, Newell JA, Devanand DP, et al. Effects of citalopram on neuropsychiatric symptoms in Alzheimer’s dementia: evidence from the CitAD study. Am J Psychiatry. 2016;173(5):473–80. Scholar
  75. 75.
    Drye LT, et al. Citalopram for agitation in Alzheimer’s disease: design and methods. Alzheimers Demen. 2012;8:121–30.CrossRefGoogle Scholar
  76. 76.
    Pollock BG, Mulsant BH, Rosen J, Sweet RA, Mazumdar S, Bharucha A, et al. Comparison of citalopram, perphenazine, and placebo for the acute treatment of psychosis and behavioral disturbances in hospitalized, demented patients. Am J Psychiatry. 2002;159(3):460–5. Scholar
  77. 77.
  78. 78.
    Beach SR, Celano CM, Sugrue AM, Adams C, Ackerman MJ, Noseworthy PA, Huffman JC. QT prolongation, Torsades de Pointes, and psychotropic medications: a 5-year update. Psychosomatics. 2018;59(2):105–22. Scholar
  79. 79.
    Zivin K, Pfeiffer PN, Bohnert AS, Ganoczy D, Blow FC, Nallamothu BK, Kales HC. Evaluation of the FDA warning against prescribing citalopram at doses exceeding 40 mg. Am J Psychiatry. 2013;170(6):642–50. Scholar
  80. 80.
    De Picker L, Van Den Eede F, Dumont G, Moorkens G, Sabbe BG. Antidepressants and the risk of hyponatremia: a class-by-class review of literature. Psychosomatics. 2014;55(6):536–47. Scholar
  81. 81.
    Greenblatt HK, Greenblatt DJ. Antidepressant-associated hyponatremia in the elderly. J Clin Psychopharmacol. 2016;36(6):545–9. Scholar
  82. 82.
    Leth-Moller KB, Hansen AH, Torstensson M, Andersen SE, Odum L, Gislasson G, et al. Antidepressants and the risk of hyponatremia: a Danish register-based population study. BMJ Open. 2016;6(5):e011200. Scholar
  83. 83.
    Thompson S, Herrmann N, Rapoport MJ, Lanctot KL. Efficacy and safety of antidepressants for treatment of depression in Alzheimer’s disease: a metaanalysis. Can J Psychiatry. 2007;52(4):248–55. Scholar
  84. 84.
    Farina N, Morrell L, Banerjee S. What is the therapeutic value of antidepressants in dementia? A narrative review. Int J Geriatr Psychiatry. 2017;32(1):32–49. Scholar
  85. 85.
    Leong C. Antidepressants for depression in patients with dementia: a review of the literature. Consult Pharm. 2014;29(4):254–63. Scholar
  86. 86.
    Nelson JC, Devanand DP. A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia. J Am Geriatr Soc. 2011;59(4):577–85. Scholar
  87. 87.
    Schwarz S, Froelich L, Burns A. Pharmacological treatment of dementia. Curr Opin Psychiatry. 2012;25(6):542–50. Scholar
  88. 88.
    Sepehry AA, Lee PE, Hsiung GY, Beattie BL, Jacova C. Effect of selective serotonin reuptake inhibitors in Alzheimer’s disease with comorbid depression: a meta-analysis of depression and cognitive outcomes. Drugs Aging. 2012;29(10):793–806. Scholar
  89. 89.
    NICE Guidelines. Accessed 3/1/18.
  90. 90.
    Lenze EJ, Stark S, Avidan MS. Alternative facts? antidepressants and falls in older adults. Am J Geriatr Psychiatry. 2017;25(12):1337–8. Scholar
  91. 91.
    Studenski and Van Swearingen, Chapter 103 Falls in Brocklehurst’s Textbook of Geriatric Medicine and Gerontology, 8th ed. 2017.
  92. 92.
    Kvelde T, Lord SR, Close JC, Reppermund S, Kochan NA, Sachdev P, et al. Depressive symptoms increase fall risk in older people, independent of antidepressant use, and reduced executive and physical functioning. Arch Gerontol Geriatr. 2015;60(1):190–5. Scholar
  93. 93.
    Lord, from Chapter 48 Falls in Hazzard’s Textbook of Geriatric Medicine and Gerontology, 7th ed. 2017.Google Scholar
  94. 94.
    Murray GR, Cameron ID, Cumming RG. The consequences of falls in acute and subacute hospitals in Australia that cause proximal femoral fractures. J Am Geriatr Soc. 2007;55(4):577–82. Scholar
  95. 95.
    Fall prevention in the cognitively impaired. Nurs Stand. 2003;17(23).
  96. 96.
    Bergh S, Selbaek G, Engedal K. Discontinuation of antidepressants in people with dementia and neuropsychiatric symptoms (DESEP study): double blind, randomised, parallel group, placebo controlled trial. BMJ. 2012;344:e1566. Scholar
  97. 97.
    Seitz DP, Gill SS, Herrmann N, Brisbin S, Rapoport MJ, Rines J, et al. Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review. Int Psychogeriatr. 2012;25(02):185–203. Scholar
  98. 98.
    Olin JT, Fox LS, Pawluczyk S, Taggart NA, Schneider LS. A pilot randomized trial of carbamazepine for behavioral symptoms in treatment-resistant outpatients with Alzheimer disease. Am J Geriatr Psychiatry. 2001;9(4):400–5. Scholar
  99. 99.
    Lonergan E, Luxenberg J. Valproate preparations for agitation in dementia. Cochrane Database Syst Rev. 2009;3:CD003945. Scholar
  100. 100.
    Tariot PN, Schneider LS, Cummings J, Thomas RG, Raman R, Jakimovich LJ, et al. Chronic divalproex sodium to attenuate agitation and clinical progression of Alzheimer disease. Arch Gen Psychiatry. 2011;68(8):853–61. Scholar
  101. 101.
    Dolder CR, Nealy KL, McKinsey J. Valproic acid in dementia: does an optimal dose exist? J Pharm Pract. 2012;25(2):142–50. Scholar
  102. 102.
    Liu CS, Ruthirakuhan M, Chau SA, Herrmann N, Carvalho AF, Lanctot KL. Pharmacological management of agitation and aggression in Alzheimer’s disease: a review of current and novel treatments. Curr Alzheimer Res. 2016;13(10):1134–44.PubMedCrossRefGoogle Scholar
  103. 103.
    Yeh YC, Ouyang WC. Mood stabilizers for the treatment of behavioral and psychological symptoms of dementia: an update review. Kaohsiung J Med Sci. 2012;28(4):185–93. Scholar
  104. 104.
    Devanand DP, Pelton GH, D’Antonio K, Strickler JG, Kreisl WC, Noble J, et al. Low-dose lithium treatment for agitation and psychosis in Alzheimer disease and frontotemporal dementia: a case series. Alzheimer Dis Assoc Disord. 2017;31(1):73–5. Scholar
  105. 105.
    Fenn HH, Sommer BR, Ketter TA, Alldredge B. Safety and tolerability of mood-stabilising anticonvulsants in the elderly. Expert Opin Drug Saf. 2006;5(3):401–16.PubMedCrossRefGoogle Scholar
  106. 106.
    Cummings JL, Schneider E, Tariot PN, Graham SM, Memantine MEM-MD-02 Study Group. Behavioral effects of memantine in Alzheimer disease patients receiving donepezil treatment. Neurology. 2006;67(1):57–63. Scholar
  107. 107.
    Howard RJ, Juszczak E, Ballard CG, Bentham P, Brown RG, Bullock R, et al. Donepezil for the treatment of agitation in Alzheimer’s disease. N Engl J Med. 2007;357(14):1382–92. Scholar
  108. 108.
    Rabins P, Rovner B, Rummans T, Schneider LS, Tariot PN. Guideline watch for the practice guideline for the treatment of patients with Alzheimer’s disease and other dementias. 2014. Retrieved from
  109. 109.
    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(2):158–64. Scholar
  110. 110.
    Wang J, Yu JT, Wang HF, Meng XF, Wang C, Tan CC, Tan L. Pharmacological treatment of neuropsychiatric symptoms in Alzheimer’s disease: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2015;86(1):101–9. Scholar
  111. 111.
    Rodda J, Morgan S, Walker Z. Are cholinesterase inhibitors effective in the management of the behavioral and psychological symptoms of dementia in Alzheimer’s disease? A systematic review of randomized, placebo-controlled trials of donepezil, rivastigmine and galantamine. Int Psychogeriatr. 2009;21(5):813–24. Scholar
  112. 112.
    Trinh NH, Hoblyn J, Mohanty S, Yaffe K. Efficacy of cholinesterase inhibitors in the treatment of neuropsychiatric symptoms and functional impairment in Alzheimer disease: a meta-analysis. JAMA. 2003;289(2):210–6.PubMedCrossRefGoogle Scholar
  113. 113.
    Klein MD, Newton W. Do cholinesterase inhibitors improve Alzheimer symptoms and functionality? J Fam Pract. 2003;52(4):279–80.PubMedPubMedCentralGoogle Scholar
  114. 114.
    Kroger E, Mouls M, Wilchesky M, Berkers M, Carmichael PH, van Marum R, Laroche ML. Adverse drug reactions reported with cholinesterase inhibitors: an analysis of 16 years of individual case safety reports from VigiBase. Ann Pharmacother. 2015;49(11):1197–206. Scholar
  115. 115.
    Maidment ID, Fox CG, Boustani M, Rodriguez J, Brown RC, Katona CL. Efficacy of memantine on behavioral and psychological symptoms related to dementia: a systematic meta-analysis. Ann Pharmacother. 2008;42(1):32–8. Scholar
  116. 116.
    Wilcock GK, Ballard CG, Cooper JA, Loft H. Memantine for agitation/aggression and psychosis in moderately severe to severe Alzheimer’s disease: a pooled analysis of 3 studies. J Clin Psychiatry. 2008;69(3):341–8.PubMedCrossRefGoogle Scholar
  117. 117.
    McShane R, Areosa Sastre A, Minakaran N. Memantine for dementia. Cochrane Database Syst Rev. 2006;2:CD003154. Scholar
  118. 118.
    Cooper JP. Buspirone for anxiety and agitation in dementia. J Psychiatry Neurosci. 2003;28(6):469.PubMedPubMedCentralGoogle Scholar
  119. 119.
    Holzer JC, Gitelman DR, Price BH. Efficacy of buspirone in the treatment of dementia with aggression. Am J Psychiatry. 1995;152(5):812.PubMedPubMedCentralGoogle Scholar
  120. 120.
    Tiller JW, Dakis JA, Shaw JM. Short-term buspirone treatment in disinhibition with dementia. Lancet. 1988;2(8609):510.PubMedCrossRefGoogle Scholar
  121. 121.
    Martinon-Torres G, Fioravanti M, Grimley EJ. Trazodone for agitation in dementia. Cochrane Database Syst Rev. 2004;4:CD004990. Scholar
  122. 122.
    Camargos EF, Pandolfi MB, Freitas MP, Quintas JL, Lima Jde O, Miranda LC, et al. Trazodone for the treatment of sleep disorders in dementia: an open-label, observational and review study. Arq Neuropsiquiatr. 2011;69(1):44–9.PubMedCrossRefGoogle Scholar
  123. 123.
    Lebert F, Stekke W, Hasenbroekx C, Pasquier F. Frontotemporal dementia: a randomised, controlled trial with trazodone. Dement Geriatr Cogn Disord. 2004;17(4):355–9. Scholar
  124. 124.
    Sultzer DL, Gray KF, Gunay I, Berisford MA, Mahler ME. A double-blind comparison of trazodone and haloperidol for treatment of agitation in patients with dementia. Am J Geriatr Psychiatry. 1997;5(1):60–9.PubMedCrossRefGoogle Scholar
  125. 125.
    Padala PR, Burke WJ, Shostrom VK, Bhatia SC, Wengel SP, Potter JF, Petty F. Methylphenidate for apathy and functional status in dementia of the Alzheimer type. Am J Geriatr Psychiatry. 2010;18(4):371–4. Scholar
  126. 126.
    Padala PR, Padala KP, Lensing SY, Ramirez D, Monga V, Bopp MM, et al. Methylphenidate for apathy in community-dwelling older veterans with mild Alzheimer’s disease: a double-blind, randomized, placebo-controlled trial. Am J Psychiatry. 2018;175(2):159–68. Scholar
  127. 127.
    Berman K, Brodaty H, Withall A, Seeher K. Pharmacologic treatment of apathy in dementia. Am J Geriatr Psychiatry. 2012;20(2):104–22. Scholar
  128. 128.
    Harrison F, Aerts L, Brodaty H. Apathy in dementia: systematic review of recent evidence on pharmacological treatments. Curr Psychiatry Rep. 2016;18(11):103. Scholar
  129. 129.
    Gannon M, Che P, Chen Y, Jiao K, Roberson ED, Wang Q. Noradrenergic dysfunction in Alzheimer’s disease. Front Neurosci. 2015;9:220. Scholar
  130. 130.
    Pauszek ME. Propranolol for treatment of agitation in senile dementia. Indiana Med. 1991;84(1):16–7.PubMedPubMedCentralGoogle Scholar
  131. 131.
    Summers WK. The management of agitation in demented patients with propranolol. J Alzheimers Dis. 2006;9(1):69–75.PubMedCrossRefGoogle Scholar
  132. 132.
    Weiler PG, Mungas D, Bernick C. Propranolol for the control of disruptive behavior in senile dementia. J Geriatr Psychiatry Neurol. 1988;1(4):226–30.PubMedPubMedCentralGoogle Scholar
  133. 133.
    Peskind ER, Tsuang DW, Bonner LT, Pascualy M, Riekse RG, Snowden MB, et al. Propranolol for disruptive behaviors in nursing home residents with probable or possible Alzheimer disease: a placebo-controlled study. Alzheimer Dis Assoc Disord. 2005;19(1):23–8.PubMedCrossRefGoogle Scholar
  134. 134.
    Wang LY, Shofer JB, Rohde K, Hart KL, Hoff DJ, McFall YH, et al. Prazosin for the treatment of behavioral symptoms in patients with Alzheimer disease with agitation and aggression. Am J Geriatr Psychiatry. 2009;17(9):744–51. Scholar
  135. 135.
    Cummings J, Isaacson S, Mills R, Williams H, Chi-Burris K, Corbett A, et al. Pimavanserin for patients with Parkinson’s disease psychosis: a randomised, placebo-controlled phase 3 trial. Lancet. 2014;383(9916):533–40. Scholar
  136. 136.
    Fox SH. Pimavanserin as treatment for Parkinson’s disease psychosis. Lancet. 2014;383(9916):494–6. Scholar
  137. 137.
    Ballard C, Banister C, Khan Z, Cummings J, Demos G, Coate B, et al. Evaluation of the safety, tolerability, and efficacy of pimavanserin versus placebo in patients with Alzheimer’s disease psychosis: a phase 2, randomised, placebo-controlled, double-blind study. Lancet Neurol. 2018;17(3):213–22. Scholar
  138. 138.
    Lee J, Choi BH, Oh E, Sohn EH, Lee AY. Treatment of Alzheimer’s disease with repetitive transcranial magnetic stimulation combined with cognitive training: a prospective, randomized, double-blind, placebo-controlled study. J Clin Neurol. 2016;12(1):57–64. Scholar
  139. 139.
    Glass OM, Forester BP, Hermida AP. Electroconvulsive therapy (ECT) for treating agitation in dementia (major neurocognitive disorder) – a promising option. Int Psychogeriatr. 2017;29(5):717–26. Scholar
  140. 140.
    Burton MC, Koeller SL, Brekke FM, Afonya AT, Sutor B, Lapid MI. Use of electroconvulsive therapy in dementia-related agitation: a case series. J ECT. 2017;33(4):286–9. Scholar
  141. 141.
    Van den Berg JF, Kruithof HC, Kok RM, Verwijk E, Spaans H-P. Electoconvulsive therapy for agitation and aggression in dementia: a systematic review. Am J Geriatr Psychiatry. 2018;28:419–34.CrossRefGoogle Scholar
  142. 142.
    Snowden JS, Thompson JC, Stopford CL, Richardson AMT, Gerhard A, Neary D, Mann DMA. The clinical diagnosis of early onset dementias: diagnostic accuracy and clinicopathological relationships. Brain. 2011;134:2478–92.PubMedCrossRefGoogle Scholar
  143. 143.
    Staekenborg SS, Su T, van Straaten EC, Lane R, Scheltens P, Barkhof F, van der Flier WM. Behavioural and psychological symptoms in vascular dementia; differences between small- and large-vessel disease. J Neurol Neurosurg Psychiatry. 2010;81(5):547–51. Scholar
  144. 144.
    O’Brien JT, Thomas A. Vascular dementia. Lancet. 2015;386(10004):1698–706. Scholar
  145. 145.
    Cruz-Jentoft AJ, Buron JA, Diago JI, Gallego R. Risperidone in the treatment of behavioural and psychological symptoms of dementia in patients diagnosed with vascular or mixed-type dementia. Int J Psychiatry Clin Pract. 2005;9(1):45–51. Scholar
  146. 146.
    Rolinski M, Fox C, Maidment I, McShane R. Cholinesterase inhibitors for dementia with Lewy bodies, Parkinson’s disease dementia and cognitive impairment in Parkinson’s disease. Cochrane Database Syst Rev. 2012;3:CD006504. Scholar
  147. 147.
    McKeith IG, Grace JB, Walker Z, Byrne EJ, Wilkinson D, Stevens T, Perry EK. Rivastigmine in the treatment of dementia with Lewy bodies: preliminary findings from an open trial. Int J Geriatr Psychiatry. 2000;15(5):387–92.PubMedCrossRefGoogle Scholar
  148. 148.
    Mori E, Ikeda M, Kosaka K, Donepezil-DLB Study Investigators. Donepezil for dementia with Lewy bodies: a randomized, placebo-controlled trial. Ann Neurol. 2012;72(1):41–52. Scholar
  149. 149.
    Boot BP, McDade EM, McGinnis SM, Boeve BF. Treatment of dementia with Lewy bodies. Curr Treat Options Neurol. 2013;15(6):738–64. Scholar
  150. 150.
    Matsunaga S, Kishi T, Iwata N. Memantine for Lewy body disorders: systematic review and meta-analysis. Am J Geriatr Psychiatry. 2015a;23(4):373–83. Scholar
  151. 151.
    Matsunaga S, Kishi T, Yasue I, Iwata N. Cholinesterase inhibitors for Lewy body disorders: a meta-analysis. Int J Neuropsychopharmacol. 2015b;19(2) Scholar
  152. 152.
    Stinton C, McKeith I, Taylor JP, Lafortune L, Mioshi E, Mak E, et al. Pharmacological management of Lewy body dementia: a systematic review and meta-analysis. Am J Psychiatry. 2015;172(8):731–42. Scholar
  153. 153.
    Kurlan R, Cummings J, Raman R, Thal L, Alzheimer’s Disease Cooperative Study Group. Quetiapine for agitation or psychosis in patients with dementia and parkinsonism. Neurology. 2007;68(17):1356–63. Scholar
  154. 154.
    Desmarais P, Massoud F, Filion J, Nguyen QD, Bajsarowicz P. Quetiapine for psychosis in Parkinson disease and neurodegenerative parkinsonian disorders: a systematic review. J Geriatr Psychiatry Neurol. 2016;29(4):227–36. Scholar
  155. 155.
    Culo S, Mulsant BH, Rosen J, Mazumdar S, Blakesley RE, Houck PR, Pollock BG. Treating neuropsychiatric symptoms in dementia with Lewy bodies: a randomized controlled-trial. Alzheimer Dis Assoc Disord. 2010;24(4):360–4. Scholar
  156. 156.
    Velayudhan L, Ffytche D, Ballard C, Aarsland D. New therapeutic strategies for Lewy body dementias. Curr Neurol Neurosci Rep. 2017;17(9):68. Scholar
  157. 157.
    Pollak P. Clozapine in drug induced psychosis in Parkinson’s disease: a randomised, placebo controlled study with open follow up. J Neurol Neurosurg Psychiatry. 2004;75(5):689–95. Scholar
  158. 158.
    Aarsland D, Perry R, Larsen JP, McKeith IG, O’Brien JT, Perry EK, et al. Neuroleptic sensitivity in Parkinson’s disease and parkinsonian dementias. J Clin Psychiatry. 2005;66(5):633–7.PubMedCrossRefGoogle Scholar
  159. 159.
    Bozymski KM, Lowe DK, Pasternak KM, Gatesman TL, Crouse EL. Pimavanserin: a novel antipsychotic for parkinson’s disease psychosis. Ann Pharmacother. 2017;51(6):479–87. Scholar
  160. 160.
    Mendez MF. Frontotemporal dementia: therapeutic interventions. Front Neurol Neurosci. 2009;24:168–78. Scholar
  161. 161.
    Riedl L, Mackenzie IR, Forstl H, Kurz A, Diehl-Schmid J. Frontotemporal lobar degeneration: current perspectives. Neuropsychiatr Dis Treat. 2014;10:297–310. Scholar
  162. 162.
    Olney NT, Spina S, Miller BL. Frontotemporal dementia. Neurol Clin. 2017;35(2):339–74. Scholar
  163. 163.
    Finger EC. New potential therapeutic approaches in frontotemporal dementia: oxytocin, vasopressin, and social cognition. J Mol Neurosci. 2011;45(3):696–701. Scholar
  164. 164.
    Jesso S, Morlog D, Ross S, Pell MD, Pasternak SH, Mitchell DG, et al. The effects of oxytocin on social cognition and behavior in frontotemporal dementia. Brain. 2011;134(Pt 9):2493–501. Scholar
  165. 165.
    Cipriani G, Ulivi M, Danti S, Lucetti C, Nuti A. Sexual disinhibition and dementia. Psychogeriatrics. 2016;16(2):145–53.PubMedCrossRefGoogle Scholar
  166. 166.
    Joller P, Gupta N, Seitz DP, Frank C, Gibson M, Gill SS. Approach to inappropriate sexual behaviour in people with dementia. Can Fam Physician. 2013;59(3):255–60.PubMedPubMedCentralGoogle Scholar
  167. 167.
    De Giorgi R, Series H. Treatment of inappropriate sexual behavior in dementia. Curr Treat Options Neurol. 2016;18(9):41.PubMedCrossRefGoogle Scholar
  168. 168.
    Sachdev PS. Inappropriate sexual behaviors in dementia. Am J Geriatr Psychiatry. 2017;25(4)PubMedCrossRefGoogle Scholar
  169. 169.
    Tune LE. An (Old) New strategy to manage BPSD. Am J Geriatr Psychiatry. 2018;26:289–90.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Christopher O’Connell
    • 1
  • Howard H. Fenn
    • 2
    Email author
  • Rita Hitching
    • 3
  1. 1.VA St. Louis Health Care SystemDepartment of Psychiatry and Behavioral Neuroscience at St. Louis University School of MedicineSt. LouisUSA
  2. 2.Department of Psychiatry and Stanford/VA Alzheimer’s CenterVA Health Care SystemPalo AltoUSA
  3. 3.Palo Alto Veterans’ Institute for Research (PAVIR), VA Palo Alto Health Care SystemPalo AltoUSA

Personalised recommendations