Behavioral and psychological symptoms of dementia include agitation, aggression, psychosis, depression, apathy and sleep disturbance and affect up to 90 percent of people with dementia. Treatment starts with finding triggers such as pain or infection and coaching caregivers; medication is reserved for dangerous or distressing symptoms. Brexpiprazole is the only FDA-approved drug for agitation in Alzheimer's dementia.
Stedfast Psychiatry treats BPSD in our offices, by telehealth with caregivers, and on site in assisted living, memory care and skilled nursing facilities through our Stedfast Living program. Our approach follows current geriatric psychiatry guidance: find and fix the cause of the behavior first, use environmental and caregiver strategies as the foundation, prescribe medication only for symptoms that are dangerous or distressing, choose the safest agent, and reduce the dose as soon as it is possible. We accept Medicare.
Symptoms of BPSD
- Agitation: restlessness, pacing, repetitive questions or movements, resisting care
- Verbal or physical aggression toward caregivers, often during bathing, dressing or toileting
- Sundowning: confusion, anxiety and restlessness that worsen in the late afternoon and evening
- Suspicion or false beliefs, such as accusing family of stealing or a spouse of infidelity
- Hallucinations, most often seeing people or animals that are not there
- Depression, tearfulness or statements of wanting to die
- Apathy: loss of initiative and interest that is often mistaken for depression
- Sleep reversal, night wandering, or sleeping most of the day
- Disinhibition, such as inappropriate comments or undressing in public
- Refusal to eat or take medications
Causes and risk factors
BPSD arise from the dementia itself, from the person's environment, and from unmet needs the person can no longer express. As disease spreads through the brain, the frontal circuits that regulate impulse, mood and judgment degrade, and the person loses the ability to interpret surroundings or communicate discomfort. A behavior is often the only language left. Pain from arthritis, constipation, a urinary tract infection, a full bladder, hunger, thirst, poor sleep, a new medication or a change in routine are the most common reversible drivers of sudden agitation, and finding them is the first job of evaluation.
The type of dementia shapes the symptoms. Alzheimer's disease commonly produces depression early, then suspicion, agitation and sleep disturbance in the middle stages. Dementia with Lewy bodies produces vivid visual hallucinations, fluctuating alertness and acting out dreams, and carries severe sensitivity to most antipsychotics. Frontotemporal dementia produces disinhibition, compulsive behavior and apathy with memory relatively spared. Vascular dementia produces apathy, emotional lability and stepwise decline. Delirium, an acute confusional state caused by infection, medication or metabolic disturbance, is frequently mistaken for a worsening of dementia and must be ruled out whenever behavior changes quickly.
Up to 90 percent of people with dementia experience at least one behavioral or psychological symptom over the course of the illness, and these symptoms are a leading cause of nursing home placement.
Source: Lyketsos et al., Alzheimer's and Dementia, 2011; Alzheimer's Association
In May 2023 the FDA approved brexpiprazole as the first medication for agitation associated with dementia due to Alzheimer's disease, based on two randomized trials showing greater reduction on the Cohen-Mansfield Agitation Inventory than placebo.
Source: US Food and Drug Administration, 2023
Antipsychotic medications carry a boxed warning for a roughly 1.6 to 1.7 times increased risk of death in elderly patients with dementia-related psychosis, mostly from cardiovascular events and infection.
Source: FDA Public Health Advisory, 2005; Schneider et al., JAMA, 2005
In the CitAD trial, citalopram 30 mg reduced agitation in Alzheimer's patients compared with placebo but was associated with QT prolongation and a small worsening in cognition, leading to recommended dose limits.
Source: Porsteinsson et al., JAMA, 2014
How we diagnose it at Stedfast Psychiatry
Evaluation starts with the question every clinician should ask before prescribing anything: what changed? We take a detailed history from caregivers or facility staff about when the behavior occurs, what precedes it, what makes it better or worse, and whether it is new. We use the Neuropsychiatric Inventory (NPI) or its nursing home version to catalog symptoms and their severity, the Cohen-Mansfield Agitation Inventory to track agitation over time, and the Cornell Scale for Depression in Dementia because standard depression questionnaires do not work when the patient cannot self-report. We screen cognition with the MoCA or MMSE to stage the dementia.
We look hard for medical causes. A urinalysis, complete blood count, metabolic panel, thyroid function and B12 are routine when behavior changes suddenly, and we assess for pain, constipation, dehydration, hearing and vision loss and sleep apnea. We review the full medication list, because anticholinergic drugs, benzodiazepines, opioids, steroids and some Parkinson's medications provoke confusion and agitation. In facilities, we review the medication administration record and incident reports and speak with the nurses who know the resident. We use the DICE framework (Describe, Investigate, Create, Evaluate) to turn that information into a plan that caregivers can carry out.
Treatment options
Behavioral and environmental strategies
Non-drug approaches are the first-line treatment for BPSD and the foundation for everything else. We coach caregivers and facility staff on the specific behavior: simplifying the environment, keeping a predictable routine, scheduling bathing and dressing at the person's best time of day, reducing noise and clutter, using daylight exposure and structured activity to protect the sleep-wake cycle, avoiding arguing or correcting false beliefs, and redirecting rather than confronting. Treating pain on a schedule rather than as needed, since the person cannot ask, often reduces agitation more than any psychiatric drug. Music, familiar objects, brief frequent contact and simple tasks that give a sense of purpose have measurable effects. For families, caregiver education and respite reduce the caregiver stress that, in turn, worsens the patient's behavior.
Medication management
Medication is appropriate when symptoms are dangerous, severely distressing to the patient or persist after behavioral measures and medical causes have been addressed. We choose the agent to fit the symptom. For depression and anxiety, and for mild to moderate agitation, SSRIs are the usual first medication. Citalopram showed a meaningful reduction in agitation in the CitAD trial, but the 30 mg dose used in that study prolongs the QT interval and worsened cognition, so we use it at a maximum of 20 mg with an ECG and often favor sertraline or escitalopram. For moderate to severe agitation in Alzheimer's dementia that has not responded to other measures, brexpiprazole (Rexulti) became the first and only FDA-approved medication in May 2023, at 2 to 3 mg daily. It carries the same boxed warning as every antipsychotic about increased mortality in elderly patients with dementia-related psychosis, and we discuss that risk plainly with families. Other antipsychotics such as risperidone, quetiapine and olanzapine remain off-label and are used at the lowest dose for the shortest time when psychosis or aggression create danger; in Lewy body dementia we avoid most of them and use quetiapine or pimavanserin only with great care. Trazodone at low dose helps sleep disturbance and sundowning. We avoid benzodiazepines, which worsen confusion and falls, and we do not use antipsychotics for wandering, calling out, restlessness or insomnia. Every psychotropic in a facility resident is reviewed for gradual dose reduction, which federal nursing home regulations require: we attempt a taper after three to six months of stability and document the outcome, because many patients no longer need the drug once the phase of illness that provoked the behavior has passed.
Caregiver and family support
Caring for someone with BPSD is one of the most stressful roles a person can hold, and caregiver depression and burnout are common. Our therapists offer caregiver counseling, including education about the disease, practical problem-solving for specific behaviors, and grief support for the losses that accumulate before death. Caregivers who are supported make better decisions, keep their relative at home longer when that is the goal, and are better able to judge when placement is right.
What to expect
For patients living at home, the first visit is in person or by video with a family caregiver present, and we ask for the medication list, recent labs and a brief diary of the behaviors. For residents of assisted living, memory care or skilled nursing facilities, our Stedfast Living providers evaluate on site, review the chart and the medication administration record, speak with nursing staff and, when possible, the family, and document a plan the facility can implement. The plan names the target behaviors, the non-drug strategies to try, any medication with its dose and the date for review. Follow-up is at two to four weeks after any medication change and then at regular intervals, with the NPI or agitation inventory repeated so decisions rest on measured change. Telehealth with a caregiver or facility nurse covers many follow-ups. Medicare Part B covers these services.
When to seek help
Seek evaluation when behavior has changed suddenly, which may signal delirium or an infection that needs same-day medical attention; when agitation or aggression is putting the patient or caregivers at risk of injury; when the person has stopped eating or sleeping; when hallucinations or false beliefs are causing fear; or when a caregiver is reaching the end of what they can manage. Depression in dementia is treatable and should not be accepted as inevitable. If the person expresses a wish to die or a caregiver is in crisis, call or text 988, the Suicide and Crisis Lifeline. If there is immediate danger of harm, call 911.
Symptom clusters and what drives them
BPSD are usually grouped into clusters, and each cluster calls for a different response. Affective symptoms, meaning depression and anxiety, are most common early and respond to SSRIs, activity and social contact. Psychotic symptoms, meaning delusions and hallucinations, appear in the middle stages, are often tolerated without medication when they do not frighten the person, and warrant an antipsychotic only when they cause fear or danger. Hyperactivity symptoms, meaning agitation, aggression, irritability and disinhibition, are the ones most tied to unmet needs and caregiver interaction, and they respond best to environmental change. Apathy is the single most common symptom across all dementias, is frequently confused with depression, and responds to structured engagement rather than medication. Sleep disturbance cuts across all stages and is addressed with light, routine and cautious use of melatonin or trazodone.
Delirium: the emergency that masquerades as dementia
When a person with dementia becomes acutely more confused, agitated or drowsy over hours to days, the cause is usually delirium rather than progression of the disease. Urinary tract infections, pneumonia, dehydration, constipation, a new medication, uncontrolled pain, a fall with an undetected head injury or a change in blood sugar are the typical culprits. Delirium is a medical emergency with high mortality if missed, and the correct response is a same-day medical evaluation, not a sedative. We teach facility staff and families to recognize the sudden change and fluctuating alertness that distinguish delirium, and we never increase psychotropic medication for a behavior change until delirium has been excluded.
Why the type of dementia changes the prescription
Dementia with Lewy bodies deserves special mention because it is common, under-diagnosed and dangerous to treat with standard antipsychotics. People with Lewy body dementia can develop severe rigidity, immobility, confusion and a potentially fatal reaction to haloperidol, risperidone and olanzapine. Visual hallucinations in this condition are often not distressing and may need no medication at all. When treatment is needed, cholinesterase inhibitors such as rivastigmine often reduce hallucinations, and quetiapine or pimavanserin are used cautiously. Frontotemporal dementia responds poorly to cholinesterase inhibitors, which can worsen behavior, and its compulsive and disinhibited symptoms sometimes improve with SSRIs. Getting the diagnosis right, in partnership with neurology, is part of prescribing safely.
Reducing medication over time
A principle of geriatric psychiatry is that BPSD are stage-dependent. The suspicion and agitation of middle-stage Alzheimer's disease frequently fade as the illness advances, which means a medication started for good reasons may become unnecessary. Federal nursing home regulations codify this through required gradual dose reduction attempts, but the same logic applies at home. We set a review date whenever we start a psychotropic, taper after three to six months of stability, and judge the result by the behavior diary and the agitation inventory rather than by impression. Successful tapers are common, and they reduce fall risk, sedation and the cardiovascular risks that come with antipsychotics.
Supporting the caregiver
The person providing care is part of the treatment system. Caregiver stress raises the patient's agitation, and caregiver depression, present in roughly a third of family caregivers, impairs the judgment and patience the role demands. We screen caregivers at every visit, offer counseling through our therapists, connect families with the Alzheimer's Association 24-hour helpline, adult day programs and respite care, and talk candidly about the point at which facility placement serves the patient better than home. When that point comes, our Stedfast Living program allows continuity: the same practice that treated the person at home continues in the facility.
Frequently asked questions
Is there a medication approved for agitation in dementia?
Yes, one. Brexpiprazole (Rexulti) was FDA-approved in May 2023 for agitation associated with dementia due to Alzheimer's disease, the first drug to carry that indication. It is used at 2 to 3 mg daily after other measures have failed and the agitation is significant. It carries the same boxed warning as all antipsychotics about increased mortality in elderly dementia patients, so it is not a first step. Everything else used for agitation, including citalopram, risperidone and quetiapine, is prescribed off-label.
Why do you want to try non-drug approaches first?
Because they work and carry no risk. Most agitation in dementia has a trigger: pain, constipation, infection, fatigue, overstimulation, a frightening care task or a caregiver's tone of voice. Removing the trigger resolves the behavior more reliably than any pill, and medications for BPSD have modest benefits with real risks, including stroke, falls, sedation and death. Guidelines from the American Psychiatric Association and the Alzheimer's Association are unanimous on this order of operations. We use medication when it is needed, not as a shortcut.
What is sundowning and what helps?
Sundowning is the worsening of confusion, anxiety and restlessness in the late afternoon and evening, probably caused by fatigue, reduced light and disruption of the body clock. Bright light exposure in the morning, physical activity during the day, a quiet predictable evening routine, closing blinds before dusk, limiting daytime naps and avoiding caffeine after noon all help. Low-dose trazodone or melatonin may be added for sleep. Antipsychotics are rarely the right answer for sundowning on its own.
My father accuses my mother of stealing from him. Should we correct him?
No. False beliefs in dementia come from memory gaps that the brain fills in, and arguing increases distress without changing the belief. Acknowledge the feeling, reassure, and redirect: help him look for the item, then move to another activity. If the suspicion is persistent, frightening or leads to aggression, an evaluation is warranted; sometimes an SSRI or, in severe cases, a low-dose antipsychotic is appropriate. Keep spare copies of frequently lost items such as glasses and wallets.
Can you see my mother in her memory care facility?
Yes. Through the Stedfast Living program our psychiatric providers make scheduled visits to assisted living, memory care, independent living and skilled nursing facilities in our Florida and South Carolina service areas. We evaluate on site, review the chart and medications, coordinate with nursing staff and the attending physician, speak with family, and follow up on a regular schedule. Visits are billed to Medicare Part B or the resident's insurance. Ask the facility whether Stedfast already visits, or call us and we will reach out to them.
What is gradual dose reduction and why does the facility keep asking about it?
Federal regulations for nursing homes require that residents on psychotropic medications, especially antipsychotics, have periodic attempts to reduce the dose unless a documented clinical reason makes that unsafe. The purpose is to avoid leaving residents on drugs they no longer need. In practice we attempt a reduction after three to six months of stability, watch closely, and restore the dose if symptoms return. Many patients come off these medications entirely because the behavior belonged to a stage of the disease that has passed.
Is depression in dementia treatable?
Yes. Depression affects a large share of people with dementia, especially in the early and middle stages, and it worsens function, appetite and cognition beyond what the dementia causes. Because the patient may not be able to describe their mood, we use the Cornell Scale, which combines caregiver report and observation. SSRIs such as sertraline are the usual treatment, alongside structured activity, social contact and daylight. Apathy, which looks like depression but lacks sadness, responds less to antidepressants and more to activity programming.
How does Medicare cover this care?
Medicare Part B covers psychiatric evaluation and medication management by our psychiatrists, nurse practitioners and physician assistants, whether delivered in our offices, by telehealth or on site in a facility, with the usual Part B coinsurance that supplemental plans typically cover. Caregiver counseling is covered when it is part of the patient's care, and family therapy sessions may be billed under the caregiver's own insurance. Medicare Advantage plans generally follow the same rules, and our staff verify coverage in advance.
Where to get treatment for behavioral and psychological symptoms of dementia
Evaluation and treatment for behavioral and psychological symptoms of dementia is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.