Key messages

  • Non-pharmacological strategies are the first line of action and require us to identify and address internal and external stressors.
  • Family and carers should be included in the development and implementation of a person-centred intervention and care plan.
  • Pharmacological strategies should be avoided where possible and used only if there is a risk of self-harm or harm to others, and only after a thorough examination.

We can use a range of strategies to help manage behavioural and psychological symptoms of dementia (BPSD).

Non-pharmacological strategies are the first line of action and require us to identify and address internal stressors, such as illness or care needs, and external stressors, such as noise and glare.

Family and carers should be included in the development and implementation of the care plan.

The following strategies may assist you develop a person centred intervention plan when these symptoms arise.1,2,3

Reassure and reduce triggers

  • Actively listen to, respond and reassure the patient.
  • Be aware that patients with dementia are very sensitive to non-verbal cues and mirror the affective behaviour of those around them; a calm and gentle manner has a positive effect.4
  • Identify and reduce triggers for BPSD.
  • Avoid surrounding the patient with too many staff at one time, minimise multiple assessments and provide the same staff.
  • Provide activities to reduce agitation and quiet areas where the patient with dementia can retreat to in order to avoid the over stimulating hospital environment. Be aware that these symptoms can be an expression of an unmet need such as pain or discomfort.5
  • Use specialist support from services such as The Dementia Behaviour Management Advisory Service which provides a 24-hour telephone support service.

Wandering

Wandering is one of the most troubling behavioural symptoms reported by family and carers. There are different patterns of wandering behaviour and different management issues and levels of risk. Screening tools can help differentiate between different types of wandering and help develop an individualised person-centred intervention6. Some strategies to try include:

  • keep objects that might encourage wandering out of sight (for example a coat or handbag)
  • make sure the patient’s room is convenient for observation, is away from stairs or elevators, and is located so the patient has to pass the nursing station to reach an exit
  • make sure all staff are alerted to the possibility of the patient wandering
  • provide appropriate opportunities for exercise and activity. The family or carer, allied health assistants or trained volunteers can help (for example, take the patient for a walk within the hospital grounds at appropriate times)
  • designate a safe place for the patient to mobilse
  • ensure the patient has identification intact at all times. Keep a description of what the patient is wearing on a daily basis and ensure a current photo is available.
  • check the patient regularly
  • consider using a bed or chair alarm.

Sundowning

Sundowning is restlessness, increasing confusion or changed behaviours in a patient with dementia that can occur late in the afternoon or early evening. Some strategies to try include:

  • use early evening routines that are familiar for the patient; ask their family or carer
  • find out what activities or strategies calm the patient (for example, warm milk, back rubs, calming music). The This is me, Information about ‘me’ for planning care in hospital, Top 5 or equivalent form completed by or with a family or carer can provide this information.
  • allow the patient to mobilise in a safe environment
  • encourage an afternoon rest, if fatigue is making sundowning worse
  • consider environmental factors, such as lighting and noise
  • avoid activities in the late afternoon that may be unsettling (for example, showers, dressings).

Anxiety or agitation

It is important tounderstand the reality the person with dementia is experiencing and validating this may help settle the patient. Some strategies to try include:

  • talk about the anxiety-producing thoughts
  • reassure the patient
  • identify and relieve the cause of the anxiety.

Aggression

Physical or verbal aggression can be triggered by issues such as fatigue, an over-stimulating environment, asking the patient too many questions at one time, asking the patient to perform tasks beyond their abilities, too many strangers in a noisy, crowded atmosphere, failure at simple tasks or confrontation with hospital staff. Some strategies to try include:

  • identify and address the triggers and underlying emotion or feelings
  • simplify the task and communication
  • ask a ‘why?’ question to understand and reduce repetitive questioning
  • if an explanation doesn’t help, a distraction or activity may diffuse the situation
  • remain calm and use a low tone of voice
  • state things in positive terms – constantly saying ‘no’; or using commands increases resistance
  • don’t force or restrain the patient.

Hallucinations or false ideas

These can be present in later stages of dementia. The person may hear voices or sounds or see people or objects. This can cause severe reactions such as fear, distress, anxiety and agitation. Strategies include:

  • don’t argue and don’t take any accusations personally
  • maintain a familiar environment, with consistent staff and routine, as much as possible
  • ignore some hallucinations or false ideas if they are harmless and aren’t causing agitation
  • avoid triggers
  • pharmacological treatment may be part of a coordinated response for some patients who may benefit from treatment with antipsychotics (see below).

Disinhibited behaviour

By understanding why a patient is behaving in this way (for example due to memory loss, disorientation or discomfort), we can help avoid triggers. A patient may have forgotten where they are, how to dress, the importance of being dressed, where the bathroom is and how to use it; they may have confused the identity of a person; they may be feeling too hot or cold or their clothes may be too tight or itchy; or are confused about the time of day and what they should be doing. Some strategies to try include:

  • respond with patience and in a gentle, matter-of-act manner
  • don’t over-react; remember it is part of the condition
  • reassure and comfort the person who may be anxious
  • gently remind the patient that the behaviour may be inappropriate
  • lead them gently to a private place
  • provide clothing that is more comfortable
  • distract the patient by providing something else to do.

Pharmacological treatment

Psychotropic drugs can play an important but limited role in managing BPSD; there are modest benefits and significant potential adverse events3. They should be avoided where possible and used only if there is a risk of self-harm or harm to others, and only after a thorough examination has eliminated other possible causes (for example pain or illness) and where behavioural and psychological interventions were proven inadequate1,3.

Pharmacological treatment will not assist with some behaviours, such as wandering or repetitive questioning7.

Work closely with doctors to monitor medication effects. Refer to a geriatrician or specialist and pharmacist as part of the care team.

Be aware that:

  • medications should be administered orally, in low doses and for a limited time
  • usage should be monitored (for effectiveness and side effects) and adjusted accordingly; medication should be ceased if not effective or if side effects are evident
  • multiple psychotropic medication are not recommended.

Pharmacological treatment should always be used in conjunction with a consistent, non-pharmacological management plan.


1. Ballarat Health Services, Understanding dementia: a guide for hospital staff. , [undated].

2. Joosse, L.L., D. Palmer, and N.M. Lang, Caring for elderly patients with dementia: nursing interventions. Nursing: Research and Reviews 2013 3: p. 107-117.

3. The Royal Australian & New Zealand College of Psychiatrists, Assessment and Management of People with Behavioural and Psychological Symptoms of Dementia (BPSD): A handbook for NSW Health Clinicians, 2013.

4. International Psychogeriatric Association. Behavioural and psychological symptoms of dementia (BPSD) educational pack. 1998 [cited 2014 13 November].

5. Alzheimer's Society Reducing the use of antipsychotic drugs: A guide to the treatment and care of behavioural and psychological symptoms of dementia 2011.

6. Dewing, J., Screening for wandering among older person’s with dementia. Nursing Older People, 2005. 17: p. 20-24.

7. Osser, D. and M. Fischer, Management of the behavioural and psychological symptoms of dementia: review of current data and best practices for health care providers., 2013, National Resource Centre for Academic Detailing.