Intended for healthcare professionals

Clinical Review State of the Art Review

Assessment and management of behavioral and psychological symptoms of dementia

BMJ 2015; 350 doi: (Published 02 March 2015) Cite this as: BMJ 2015;350:h369
  1. Helen C Kales, professor of psychiatry; director, program for positive aging; associate director for mental health and aging research, geriatrics center, University of Michigan; research scientist, VA Center for Clinical Management Research and geriatric research education and clinical center, VA Ann Arbor Healthcare System123,
  2. Laura N Gitlin, professor, schools of nursing and medicine; director, center for innovative care in aging, Johns Hopkins University456,
  3. Constantine G Lyketsos, Elizabeth Plank Althouse professor; director, Johns Hopkins Memory and Alzheimer’s Treatment Center7
  1. 1Section of Geriatric Psychiatry, Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, USA
  2. 2Department of Veterans Affairs, Center for Clinical Management Research, Ann Arbor, MI, USA
  3. 3Geriatric Research Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
  4. 4Department of Community Public Health, School of Nursing, Johns Hopkins University, Baltimore, MD, USA
  5. 5Division of Geriatrics and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
  6. 6Center for Innovative Care in Aging, Johns Hopkins University, Baltimore, MD, USA
  7. 7Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview and Johns Hopkins University, Baltimore, MD, USA
  1. Correspondence to: H C Kales kales{at}


Behavioral and psychological symptoms of dementia include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of inappropriate behaviors. One or more of these symptoms will affect nearly all people with dementia over the course of their illness. These symptoms are among the most complex, stressful, and costly aspects of care, and they lead to a myriad of poor patient health outcomes, healthcare problems, and income loss for family care givers. The causes include neurobiologically related disease factors; unmet needs; care giver factors; environmental triggers; and interactions of individual, care giver, and environmental factors. The complexity of these symptoms means that there is no “one size fits all solution,” and approaches tailored to the patient and the care giver are needed. Non-pharmacologic approaches should be used first line, although several exceptions are discussed. Non-pharmacologic approaches with the strongest evidence base involve family care giver interventions. Regarding pharmacologic treatments, antipsychotics have the strongest evidence base, although the risk to benefit ratio is a concern. An approach to integrating non-pharmacologic and pharmacologic treatments is described. Finally, the paradigm shift needed to fully institute tailored treatments for people and families dealing with these symptoms in the community is discussed.


  • HCK and LNG were supported in part by R01NR014200. CGL was supported in part by the Johns Hopkins Alzheimer’s Disease Research Center (P50AG005146).

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: HCK has received grant support through the National Institutes of Health (NIH) and Department of Veterans Affairs. LNG has received grant support through NIH, Alzheimer’s Association; she is a member on the FallAdvisory Committee for Phillips Lifeline and has received honorariums for various speaking engagements. CGL has received grant support (research or continuing medical education) from the National Institute of Mental Health, the National Institute on Aging, Associated Jewish Federation of Baltimore, Weinberg Foundation, Forest, GlaxoSmithKline, Eisai, Pfizer, AstraZeneca, Lilly, Ortho-McNeil, Bristol-Myers, Novartis, the National Football League (NFL), Elan, and Functional Neuromodulation;he is a consultant or adviser for AstraZeneca, GlaxoSmithKline, Eisai, Novartis, Forest, Supernus, Adlyfe, Takeda, Wyeth, Lundbeck, Merz, Lilly, Pfizer, Genentech, Elan, the NFL Players Association, NFL Benefits Office, Avanir, and Zinfandel and he has received honorariums or travel support from Pfizer, Forest, GlaxoSmithKline, and Health Monitor.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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