A Clinician's Guide to The Management of Behavioral and Psychological Symptoms of Dementia in The Era of Boxed Warning-View Presentation

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Video Summary

The session on treating behavioral and psychological symptoms of dementia (BPSD) covered epidemiology, neurobiology, assessment, management, and controversies in treatment. BPSD includes affective symptoms (depression, anxiety, apathy), psychosis (delusions, hallucinations), agitation, aggression, and sleep disturbances. These symptoms are prevalent—65%-90% of dementia patients exhibit at least one disruptive behavior, increasing with disease severity and environment (community vs nursing home). BPSD fluctuates, can precede cognitive symptoms, and complicates care.<br /><br />Assessment emphasizes thorough history, medical and neurological evaluation, collateral information, and use of rating scales like the Neuropsychiatric Inventory. Reversible causes (e.g., infections, pain, medications) must be ruled out. Non-pharmacological interventions—caregiver education, environmental modifications, cognitive stimulation—show benefits comparable to medications with fewer risks.<br /><br />Pharmacological treatment is individualized and reserved for cases where non-pharmacological methods fail or in psychiatric emergencies. Medications include cholinesterase inhibitors and memantine for cognitive support, SSRIs (sertraline, citalopram) for depression/anxiety, atypical antipsychotics (risperidone, brexpiprazole) for psychosis/agitation, mood stabilizers (carbamazepine occasionally), and novel options like cannabinoids and propranolol in select cases. Benzodiazepines are generally discouraged due to adverse effects.<br /><br />Antipsychotics carry warnings for increased mortality (1.6–1.7-fold), especially in the first 8-12 weeks, with dose-dependent risk for cerebrovascular events and cognitive decline. Close monitoring, informed consent, and minimal effective dosing with trial discontinuation are stressed. Emerging therapies include transcranial magnetic stimulation and electroconvulsive therapy.<br /><br />Treating dementia-related depression, apathy, and "quiet" psychosis involve careful clinical judgment, often prioritizing non-drug approaches. Sensory impairments exacerbate symptoms, highlighting comprehensive care. Overall, managing BPSD requires multidisciplinary, patient-tailored strategies balancing symptom control and medication risks.

Keywords

Behavioral and Psychological Symptoms of Dementia

BPSD

Dementia

Epidemiology

Neurobiology

Assessment

Management

Non-pharmacological interventions

Pharmacological treatment

Antipsychotics

Depression in dementia

Apathy

Psychosis