Background for Fast Fact #498: Behavioral and psychological symptoms of dementia (BPSD) affect 97% of individuals with dementia (1). Common BPSD symptoms include agitation, depression, anxiety, delusions, sleep disturbances, and “sundowning” (1). Other Fast Facts cover delirium management (Fast Fact #1, Fast Fact #60, Fast Fact #397) and general dementia care (Fast Fact #150, Fast Fact #174, Fast Fact #388, Fast Fact #455). This Fast Fact reviews non-pharmacological management of BPSD; Fast Fact #499 reviews pharmacological management of BPSD.

Recognizing BPSD vs delirium: Time is the major distinguishing factor between BPSD and delirium. With BPSD, a pattern of behaviors emerges over weeks, months, years, while the onset of delirium occurs acutely (e.g., hours or days) and usually in response to a specific medical issue(s) (medication, infection, etc.) (2). Additionally, in delirium, the level of consciousness and attention are greatly impaired, whereas attention impairment usually is not seen until late in the trajectory of dementia. Not every untoward behavior such as anger, frustration, etc. in a patient with dementia is pathological. Patients with dementia should be allowed to experience the full range of emotions and manifest proportional behaviors without fear of clinical labeling. BPSD is diagnosed only when the emotional or behavioral responses is persistent and significantly impacts patients, their caregivers, or their relationships.

BPSD non-pharmacologic management: The initial approach involves understanding baseline behaviors and identifying previously effective management strategies. Address reversible causes, such as infections, dehydration, or uncontrolled symptoms like constipation, urinary retention, and pain which may contribute to irritability. Non-pharmacologic treatments are first line as they are more evidence-based, individualized, and safe (1). Pharmacologic management is reserved for refractory cases or when there is imminent risk of harm to the patient or others (3).

Behavioral Management Techniques: These are personalized care strategies that incorporate caregiver input to improve communication, patient-centered care, and understanding of the underlying reasons for the behavior (4,5). Techniques vary but general approaches include redirecting to calming activities, maintaining a consistent routine, reassuring patients with simple language, and avoiding unnecessary arguments.  More formalized techniques have been described in the published literature such as: person-centered bathing (identifying personalized needs during bathing time), dementia mapping (observing patient behavior and interactions to understand patient desires and needs), token economics (positively reinforcing good behaviors), progressive muscle relaxation (having patients tense certain muscles and then progressively relax), caregiver education (training caregivers on problem solving, verbal/non-verbal communication, and encouraging enjoyable events for patients) (4,5); and tailored outpatient activity programs (e.g., a 3-month program based upon input of an occupational therapist) (6). A systematic review suggests that behavioral management techniques improve outcomes for residents and staff, and a meta-analysis supports formalized training of caregivers in these techniques (7,8).

Music therapy: Individualized music therapy may reduce acute agitation in patients with dementia in nursing homes and in the acute hospital, although the overall effect is mixed due to large heterogeneity between studies (1,9,10). In one study, music therapy improved depressive symptoms when used for more than 6 weeks (11). Methods range from working with music professionals to passive listening to active involvement in music (singing or playing an instrument) (1).

Reminiscence therapy: This involves eliciting memories from a patient’s past, often using tools such as photographs, objects, or music to facilitate the process. In the published literature it is described as a one-on-one or group activity with a trained therapist, so the effectiveness of ad hoc behavioral techniques involving reminiscence is unknown. One meta-analysis found reminiscence therapy to have superior efficacy in improving neuropsychiatric symptoms when compared with other non-pharmacologic BPSD strategies such as massage therapy and individualized nursing (1,12).

Aromatherapy can be implemented by a certified aromatherapist, but it can also be administered by caregivers through topical or massage application, indirect inhalation, or using water-based treatments like baths or soaks infused with essential oils (4). Lavender and Melissa oil have shown effectiveness in reducing agitation, but there is no supporting evidence for other BPSD symptoms (1,4).

Light therapy:  Usually involves full-length spectrum bright lights or wavelength-specific (blue green) delivered to patients at various points of the day via a special light apparatus (13). Small studies suggest it may help maintain the sleep-wake cycle, reduce nighttime awakenings, and improve sleep quality (13).

Exercise therapy: While there is large heterogeneity in types of exercise, duration, and frequency (e.g. Tai Chi therapy, balancing on one leg, arm resistance exercises, stretching), the consensus is to tailor to patient’s individual symptoms and needs; this is more favorable than a dogmatic approach in which the patient is forced to engage in a specific amount and type of exercise.  Exercise therapy may help alleviate overall symptoms of BPSD and depression over time (1,14,15).

Other interventions include animal-assisted therapy, massage therapy, reality orientation, validation therapy, and pairing patients with specific nurse that they seem more comfortable with (1).

References 

1. Cho E, Lee JY, Yang M, et al. Symptom-specific non-pharmacological interventions for behavioral and psychological symptoms of dementia: An umbrella review. International Journal of Nursing Studies. 2024;159:104866. doi:10.1016/j.ijnurstu.2024.104866.
2. Cloak N, Schoo C, Al Khalili Y. Behavioral and Psychological Symptoms in Dementia. In: StatPearls. StatPearls Publishing; 2024. Accessed December 5, 2024. http://www.ncbi.nlm.nih.gov/books/NBK551552/.
3. Ooi CH, Yoon PS, How CH, et al. Managing challenging behaviours in dementia. Singapore Med J. 2018;59(10):514-518. doi:10.11622/smedj.2018125.
4. Abraha I, Rimland JM, Trotta FM, et al. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series. BMJ Open. 2017;7(3):e012759. doi:10.1136/bmjopen-2016-012759.
5. O’Neil M, Freeman M, Christensen V, et al. A Systematic Evidence Review of Non-Pharmacological Interventions for Behavioral Symptoms of Dementia. Published online March 2011. 
6. De Oliveira AM, Radanovic M, Homem De Mello PC, et al. An intervention to reduce neuropsychiatric symptoms and caregiver burden in dementia: Preliminary results from a randomized trial of the tailored activity program–outpatient version. Int J Geriatr Psychiatry. 2019;34(9):1301-1307. doi:10.1002/gps.4958.
7. Carrier D, Toulouse É, Rochefort CM. Staff Training Interventions to Prevent or Reduce Behavioural and Psychological Symptoms of Dementia in Nursing Home Residents: A Mixed Methods Systematic Review. Dement Geriatr Cogn Disord. 2023;52(3):117-146. doi:10.1159/000530503.
8. Brodaty H, Arasaratnam C. Meta-Analysis of Nonpharmacological Interventions for Neuropsychiatric Symptoms of Dementia. AJP. 2012;169(9):946-953. doi:10.1176/appi.ajp.2012.11101529.
9. Hillebrand MC, Weise L, Wilz G. Immediate effects of individualized music listening on behavioral and psychological symptoms of dementia: A randomized controlled trial. Int J Geriatr Psychiatry. 2023;38(3):e5893. doi:10.1002/gps.5893.
10. Belenchia EJ. An individualized music listening program to reduce agitation in hospitalized patients with Alzheimer’s disease and related dementias. Geriatric Nursing. 2023;52:157-164. doi:10.1016/j.gerinurse.2023.06.003.
11. Li HC, Wang HH, Lu CY, et al. The effect of music therapy on reducing depression in people with dementia: A systematic review and meta-analysis. Geriatric Nursing. 2019;40(5):510-516. doi:10.1016/j.gerinurse.2019.03.017.
12. Li W, Xu X, Wu F, et al. Comparative efficacy of non‐pharmacological interventions on behavioural and psychological symptoms in elders with dementia: A network meta‐analysis. Nursing Open. 2021;8(6):2922-2931. doi:10.1002/nop2.1049.
13. Tan JSI, Cheng LJ, Chan EY, et al. Light therapy for sleep disturbances in older adults with dementia: a systematic review, meta-analysis and meta-regression. Sleep Medicine. 2022;90:153-166. doi:10.1016/j.sleep.2022.01.013.
14. Dyer SM, Harrison SL, Laver K, et al. An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia. Int Psychogeriatr. 2018;30(3):295-309. doi:10.1017/S1041610217002344.
15. Legere LE, McNeill S, Schindel Martin L, et al. Nonpharmacological approaches for behavioural and psychological symptoms of dementia in older adults: A systematic review of reviews. Journal of Clinical Nursing. 2018;27(7-8). doi:10.1111/jocn.14007.

Author Affiliations: 1Georgetown University School of Medicine; Washington DC; 2George Washington University Hospital; Washington DC; 3Medstar Harbor Hospital; Baltimore, MD.
Conflicts of Interest: None to report.
Version History:  Originally edited by Sean Marks MD; first electronically published in December 2024.