What are behaviours and psychological symptoms of dementia?

Behaviours and psychological symptoms of dementia (BPSD) refer to a range of non-cognitive symptoms common among people with dementia. The majority of people with dementia will experience at least one type of BPSD as their dementia progresses (Tible et al. 2017). Symptoms may vary in type and severity on a day-by-day basis and as a person’s dementia progresses. BPSD can have a significant impact on people with dementia, their carers and family, and has been associated with premature admission to residential care, increased hospitalisation, distress for carers and reduced functional ability for the person with dementia (Cunningham, Macfarlane and Brodaty 2019).

Language surrounding behaviours and psychological symptoms of dementia (BPSD)

In this report, the term ‘behaviours and psychological symptoms of dementia (BPSD)’ is used to describe non-cognitive symptoms common among people with dementia. While there is concern that use of this term can lead to the underlying causes or needs of a person’s behaviour being ignored, it remains the preferred term in a clinical context (Cunningham, Macfarlane and Brodaty 2019). 

This report presents information on the prevalence of select symptoms using available data. However, understanding the causes of BPSD is a key information gap. There are a range of underlying causes, from physiological changes due to dementia to unmet needs or physical ailments. These underlying causes can differ between individuals, and management of symptoms requires person-centred care. BPSD support advocates for a focus on understanding why behaviours are occurring, rather than a focus on symptoms themselves. 

Measuring BPSD

The Neuropsychiatric Inventory (NPI) is the primary measure of BPSD within clinical settings in Australia. It assesses a wide range of behaviours, rating severity, frequency and carer distress for 12 domains. These include:

  • Delusions: where client has beliefs that are known to not be true. Examples include insisting that people are trying to harm them or steal from them
  • Irritability/lability: where client is irritated or easily disturbed. This includes very changeable moods or abnormal impatience
  • Hallucinations: where client has hallucinations such as false visions or hearing false voices
  • Agitation/aggression: where client has periods when they refuse to cooperate or won’t let people assist them
  • Depression/dysphoria: where client appears sad or depressed
  • Anxiety: where client is very nervous, worried, or frightened for no apparent reason
  • Euphoria: where client has a persistent and abnormally good mood or finds humour where others do not
  • Apathy: where client has lost interest in the world around them, or is presenting as apathetic or indifferent
  • Disinhibition: where client appears to act impulsively without thinking. Examples include doing or saying things that are not usually said/done
  • Aberrant motor activity: where client paces, or does things repetitively such as opening closets or draws
  • Night-time behavioural disturbances: where client has difficulty sleeping, wandering at night or disturbing carer sleep
  • Appetite and eating abnormalities: where client has had changes in appetite, weight, or eating habits (including food preference) (APA 2011).

The NPI is administered to caregivers of people with dementia. A screening question is asked about each sub-domain, and if a response indicates there is an issue in a particular sub-domain, the caregiver is then asked further questions about that sub-domain. Further questions include a rating of severity, frequency and distress the symptoms causes on a 4-point, 3-point and 5-point scale respectively (APA 2011). The Neuropsychiatric Inventory – Questionnaire (NPI-Q), Neuropsychiatric Inventory – Nursing Home (NPI-NH) and Neuropsychiatric Inventory – Clinician (NPI-C) are all validated against the NPI but vary in their administration.

To comprehensively plan for dementia and aged care-related service delivery, greater understanding of BPSD is needed. BPSD is associated with poorer prognosis, greater caregiver and nursing-home staff stress and earlier institutionalisation (Brodaty, Draper and Low 2003). As such, the complex care needs involved in managing BPSD are crucial to understand when designing dementia support services and residential care needs.

For more information on the support services available, see Dementia Support Australia.