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Practice Clinical Updates

Managing neuropsychiatric symptoms in patients with dementia

BMJ 2022; 376 doi: (Published 25 January 2022) Cite this as: BMJ 2022;376:e069187
  1. Jennifer A Watt, geriatrician1 2,
  2. Wade Thompson, pharmacist3 4,
  3. Roger Marple, patient partner,
  4. Deborah Brown, nurse practitioner5,
  5. Barbara Liu, geriatrician2
  1. 1Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Canada
  2. 2Division of Geriatric Medicine, Department of Medicine, University of Toronto
  3. 3Women’s College Research Institute, Toronto
  4. 4Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
  5. 5Lawrence S Bloomberg Faculty of Nursing, University of Toronto
  1. Correspondence to J A Watt jennifer.watt{at}

What you need to know

  • Non-medical interventions such as psychological treatments and psychosocial and environmental modifications are recommended for people with dementia who experience neuropsychiatric symptoms such as agitation, aggression, and depression

  • Evidence of low to moderate quality shows that multidisciplinary care and non-medication interventions are as effective, or more so, than medications (eg, antipsychotics) for reducing neuropsychiatric symptoms

  • Avoid prescribing medications in lieu of antipsychotics (eg, antidepressants and anticonvulsants) because they are associated with potential harms in people with dementia (eg, risk of fall or fracture)

  • Develop person centred and measurable treatment goals and re-evaluate these at regular intervals

  • Support change at an organisational level by establishing an interprofessional team responsible for psychotropic medication stewardship, and agree on criteria for appropriateness of psychotropic medication, educate care staff, inform and involve family and friend carers, and establish a process for regular review of medications

Neuropsychiatric symptoms such as depression and agitation are reported in 11% to 90% of community dwelling patients with dementia, as per a systematic review published in 2015.1 These symptoms are associated with earlier admission to nursing homes and earlier functional decline in people with dementia, and cause distress for carers.234

Neuropsychiatric symptoms can be challenging to treat in people with dementia. Access to multidisciplinary care teams that can identify and treat underlying causes is often limited. Little evidence is available on interventions to lessen the severity and burden of symptoms. Guidelines from the National Institute for Health and Care Excellence (NICE) recommend offering non-medication interventions as initial management for these symptoms.5 In many countries, Choosing Wisely campaigns emphasise non-medication interventions and recommend against use of antipsychotics as a first choice to treat these symptoms because of limited benefit and potential to cause harm, including premature death.6

In this article we discuss how healthcare professionals can …

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