Management of the behavioral and psychological symptoms of dementia

More than 50% of people with dementia experience behavioral and psychological symptoms of dementia (BPSD). BPSD are distressing for patients and their caregivers, and are often the reason for placement into residential care. The development of BPSD is associated with a more rapid rate of cognitive decline, greater impairment in activities of daily living, and diminished quality of life (QOL). Evaluation of BPSD includes a thorough diagnostic investigation, consideration of the etiology of the dementia, and the exclusion of other causes, such as drug-induced delirium, pain, or infection. Care of patients with BPSD involves psychosocial treatments for both the patient and family. BPSD may respond to those environmental and psychosocial interventions, however, drug therapy is often required for more severe presentations. There are multiple classes of drugs used for BPSD, including antipsychotics, anticonvulsants, antidepressants, anxiolytics, cholinesterase inhibitors and NMDA modulators, but the evidence base for pharmacological management is poor, there is no clear standard of care, and treatment is often based on local pharmacotherapy customs. Clinicians should discuss the potential risks and benefits of treatment with patients and their surrogate decision makers, and must ensure a balance between side effects and tolerability compared with clinical benefit and QOL.