Treatment-Resistant Neuropsychiatric Symptoms in Dementia: Development of a Conceptual Framework

To develop 2 practice-informed conceptual frameworks for treatment-resistant neuropsychiatric symptoms (TR-NPS) in dementia-1 for community-based care and 1 for hospital-based care.

Qualitative, conceptual study examining the ethical, clinical, and existential dimensions of TR-NPS in dementia.

The work drew on routine clinical practice in inpatient psychogeriatric units and community-based dementia services.

We conducted a targeted PubMed/MEDLINE review and structured, consensus-based discussions among a multidisciplinary team. Reflexive thematic analysis was used to identify key themes.

We developed 2 practice-informed conceptual frameworks (community and hospital) supported by 4 overarching themes: (1) the need for proper recognition of TR-NPS to tailor management; (2) differing trajectories and decision-making processes at home vs in hospital; (3) the importance of addressing multidimensional suffering and preserving dignity; and (4) the need for early integration of palliative care principles, practices, and specialist teams.

TR-NPS in advanced dementia mark a threshold for timely recognition and a shift from further pharmacologic escalation toward proportionate, goal-concordant, dignity-preserving care that explicitly addresses multidimensional suffering and aligns with patient values. Early, collaborative involvement of specialist palliative care teams, together with structured caregiver support, may reduce unwarranted variation and promote consistent, person-centered practice across community and hospital settings. Future work should operationalize criteria and referral triggers for TR-NPS, develop setting-adaptable decision tools and pathways, and evaluate models of early palliative care comanagement using outcomes that emphasize comfort and dignity for patients and caregivers.