Behavioural & Psychological Symptoms

Behavioural and psychological symptoms of dementia
Contents
This section of the Dementia Resource Guide contains the following sections:
Overview 7.02
Understanding the causes 7.07
Behavioural assessment tools 7.13
Responding to symptoms and behaviours 7.19
Alternative and complimentary therapies 7.27
Behavioural and psychological symptoms of dementia 7.01

www.health.gov.au/dementia National Dementia Helpline FreecallTM 1800 100 500
Overview
Introduction
People with dementia may experience behavioural and psychological symptoms
(BPSD) during the course of their illness. These may include:
Behavioural symptoms; screaming, restlessness, physical aggression,
agitation, wandering, culturally inappropriate behaviours, sexual disinhibition,
hoarding, cursing and shadowing.
Psychological symptoms; anxiety, depressive mood, hallucinations, delusions
and psychosis.
It is difficult to estimate the rate of BPSD as different symptoms occur during

different stages of dementia. Symptoms such as depression are more likely to occur
earlier, while agitation is more likely in the latter stages (Refer to Depression
assessment). It is generally estimated that BPSD occur in 70-90% of people with
dementia.
The causes of BPSD are not clear but changes in behaviour may be triggered by
biological, psychological, social or environmental factors. For example, a person with
dementia who previously seemed to enjoy having a bath may suddenly begin
screaming during this activity. This may be due to changes in the brain or perhaps the
person simply finds the water too cold but cannot communicate this. Understanding
what has caused the change in behaviour can help address or modify the behaviour.
BPSD may present challenges for the person with dementia and their family and
carers. Untreated BPSD can decrease the quality of life for everyone concerned and
may result in premature placement in a residential facility. However, research has
shown that BPSD respond well to a combination of non-medication and medication
treatments, which in turn can reduce family and carer stress (Refer to Caring for
families and carers and Caring for service providers).
Summary
Living and caring for someone with dementia who is experiencing changing
behaviours can be confusing and stressful. Even in ideal situations, families and carers
can lose patience and subsequently feel angry or guilty. However, it is important to
know there are strategies and medications that can be used to help.

Overview
Personal story Mr Nguyen
Menka was a Personal Care Attendant who was working with a new staff member,
Amy, in a residential aged care facility.
Whats with Mr Nguyen tonight? Hes giving everyone grief, said Amy as she came
into the kitchen, carrying a plate of food.
What do you mean, hes usually so polite, asked Menka.
Well hes being really uncooperative, he didnt want his dinner, and he yelled at me
when I tried to help him to the table.
Menka paused as she thought about what Amy had said. No, thats not like him. I
wonder whats wrong.
Well, hes got dementia, replied Amy. Maybe he doesnt like his dinner and hes
just making a fuss.
Menka had trained in dementia care and knew it was important to investigate sudden
changes in the behaviour of a resident. She also knew that dementia could cause
unusual behaviour, but in her experience people were too quick to blame dementia. It
was important to remember that other things could change behaviour and the most
common causes were pain or the onset of an illness.

Menka found Mr Nguyen in his room, and noticed he didnt look well. He was
flushed, dazed, and didnt seem to know where he was. He was mumbling and
muttering, speaking English and Vietnamese, but not making any sense. Occasionally
he called for his wife.
It was surprising the symptoms had come on so quickly; only an hour ago Menka had
seen him in the recreation room playing cards, and he had seemed fine.
Menka called for assistance and told the Registered Nurse on duty about Mr Nguyen.
The nurse called in the doctor who found that Mr Nguyen had a chest infection, which
was the likely cause of his changed behaviour. The doctor prescribed antibiotics for
Mr Nguyen, and within a few days he was back to his usual self.
Menka was glad she had been able to get the right help for Mr Nguyen. She
remembered overhearing a colleague become cross with another resident, Mrs Brown,
who was moaning. The colleague told Mrs Brown to stop being so noisy. Afterwards,
Menka stopped to help Mrs Brown, who was cold and wanted her slippers. Moaning
was the only means she had of communicating. Once she had her slippers were on,
she settled down.
There is always a cause for behaviour, whether or not it is related to dementia.

Sometimes simple things like not having glasses on or a hearing aid in place, or being
uncomfortable could cause a change, and by identifying and correcting this, the
person usually settles.

Overview
Recommended resources
Name of resource and Brief description and type of Target

where it is available resource setting
Family Caregiver Alliance. Help sheet. Provides some practical

(2004). Caregivers guide to
understanding dementia
strategies for managing some of the
behavioural and psychological symptoms
G
behaviours. of dementia. Emphasises effective
www.caregiver.org communication.
[ > Fact sheets &
publications > Caregiving
issues & strategies]
Fearnley, K. (2006). For Booklet. Information and advice for

Health Scotland. Coping
with dementia: A practical
people who care for individuals with
moderate to severe dementia. Provides
C
handbook for carers. practical advice on coping with changes
www.healthscotland.com throughout the dementia journey.
[ > Resources > Publications
> Publications search]
Mace, N.L., & Rabins, P.V. Book. A comprehensive resource for

(1999). The 36-hour day
(3rd Ed.). Baltimore: The
families and carers of people with
dementia. Includes practical information
C
John Hopkins University regarding how to manage some of the
Press. behavioural and psychological symptoms
ISBN: 0801861489 of dementia.
Check your local library or
for purchase.

International Educational pack. A detailed summary of
Psychogeriatric Association.
(IPA). (2002). Behavioural
a broad range of issues related to BPSD
such as aetiology, the role of care-givers,
H
and Psychological non-pharmacological and
symptoms of Dementia pharmacological management and cross R
(BPSD) Educational Pack. cultural considerations. Also includes a
www.ipa-online.org separate module for primary care
[ > Programs > Task forces practitioners with guidelines for
> BPSD] management of BPSD (non-
pharmacological and pharmacological).
Scottish Intercollegiate Guidelines. Detailed evidence-based

Guideline Network (SIGN).
(2006). Management of
information on screening and diagnosis
and pharmacological and non-
G
patients with dementia: A pharmacological interventions. Provides
national clinical guideline. recommendations according to the level of
Edinburgh: SIGN. supporting research evidence. Also
www.sign.ac.uk includes good practice points based on
[ > Guidelines > Published expert consensus. Readers should refer to
guidelines > By number > the Clearinghouse summary FDA warning
86] regarding recommendations for the use of
some atypical 2nd generation
antipsychotic medications.
www.guideline.gov
Symbol Explanation
C Community
H Hospital setting
R Residential care setting
G General
Light reading
Medium level resource
In depth, detailed resource
Underlined text Refer to glossary for definition

Understanding the causes
Introduction
Although Behavioural and Psychological Symptoms of Dementia (BPSD) have long
been recognised as a common feature of dementia, understanding the causes has only
recently been a focus of dementia research. As a result, we are still in the early stages
of understanding why and how they present and factors that influence the
management of behaviours of concern.
There is agreement among researchers that the causes of BPSD are a complex
combination of biological, environmental and social factors. While dementia cannot
be cured, BPSD are often treatable and respond well to medication and/or non-
medication treatments. In particular, the environmental and social factors that trigger
or exacerbate behaviours of concern can be modified to enhance quality of life. This is
particularly important, as untreated BPSD in the person with dementia is often the
primary reason for admission to residential care.
Some of the factors that may contribute to BPSD are as follows:
Biological:
Genetic abnormalities related to the structure of particular parts of the brain.
Changes in chemicals in the brain.
Changes in the structure of different parts of the brain due to dementia.
It is important to note that the relationship between BPSD and changes in the
brain of the person with dementia is still unclear and requires further research
before definite conclusions can be drawn.
Medical:
Conditions such as constipation, infection, pain, dental problems and arthritis. The
person with dementia may be unable to articulate the pain they are experiencing
and instead may express their distress by vocalising or becoming aggressive.
Co-morbid conditions such as delirium, depression, anxiety or psychosis.
Individuals with dementia are more susceptible to delirium and the
illnesses/environmental stressors that lead to delirium (Refer to Delirium
assessment and Depression assessment).
Medication side effects can be numerous and may have a significant effect on a
persons behaviour (Refer to Medical treatment options).
Hearing or vision impairment that is not well managed (for example,
malfunctioning hearing aids may lead to frustration and changed behaviours).
Sleep disturbances are common in people with dementia and can cause agitation
and restlessness during the day and night.
Environmental and social:
Changes in social routine (for example, alteration in meal times or introduction of
a new care routine can cause confusion and a feeling of loss of control for the
person with dementia, contributing to behaviours of concern).
Change in environment (for example, relocation to a new room or home can
increase agitation and disorientation).
Families and carers:

Knowledge about dementia, BPSD and management strategies. A lack of
understanding about the changes dementia can bring about in a persons
functioning and behaviour can create confusion and frustration for families and
carers. For example, families and carers may falsely believe the person can control
their behaviour leading to caregivers feeling hurt, unappreciated and/or frustrated.
This in turn may cause them to become angry, which is likely to further distress
the person with dementia. Families and carers who have not received information
on responding to these behaviours may use ineffective strategies that can actually
exacerbate the behaviour.
Stress levels. Caring for a person with dementia who is demonstrating changed
behaviours can be frustrating and stressful. It is normal to lose patience at times
and this can affect how the person with dementia behaves.
Level of community or organisation support. Families and carers who have
limited support and breaks from caring for a person with dementia are at risk of
burnout. It is difficult to respond consistently when feeling unsupported or worn
out.
Recommendations
Although it may be difficult to identify the specific triggers for changes in behaviour,
it is important to rule out factors that can be controlled or treated. This includes:
Medical conditions such as constipation and infection. These are treatable and
may reduce the occurrence of BPSD in some individuals.
Delirium is the most common cause of a sudden change in behaviour. Many
factors (environmental, medical and individual) may lead to delirium and the
symptoms can be similar to those of BPSD. It is important to investigate and treat
the underlying cause (Refer to Delirium assessment).
Co-morbid conditions such as depression and anxiety. These can contribute to
BPSD and may require specialist diagnosis and intervention (Refer to Depression
assessment).
Any changes in behaviour require a thorough and detailed assessment that includes
information about the behaviour, the medical and social history of the person with the
behaviour and the physical and social environment. Families and carers should be on
the lookout for any changes and consider all possible causes.

Summary
There are a wide range of factors that can influence the manifestation of BPSD,
including the person, the environment and changes in the brain due to dementia. It is
essential that medical conditions, such as delirium, are quickly identified and treated.
Although BPSD can be stressful and perhaps even frightening at times, it is important
to remember that it is the condition creating the behaviour.

Understanding the causes

Alzheimers Australia. DVD or VHS. An audiovisual resource

(2004). Understanding the
brain and behaviour.
that clearly explains the functioning of the
brain and how it is related to behaviour.
G
www.alzheimers.org.au Includes real case examples that illustrate
Available for purchase the information provided.
through Alzheimers
Australia on-line book shop
or may be borrowed from the
local state or territory
Alzheimers association.
Alzheimers Australia. Help sheet. Describes a range of potential

(2005). Help sheet 5.2:
Problem solving.
causes or triggers for behavioural and
psychological symptoms associated with
G
www.alzheimers.org.au dementia, including factors related to the
[ > Publications & resources individuals health, their environment, the
> Helpsheets & update sheets task being undertaken and
> Changed behaviours and communication.
dementia]
Alzheimer's Society (UK). Website. As dementia develops, it can

(2008). Unusual behaviour.
www.alzheimers.org.uk
cause behavioural changes. This website
explains behaviours commonly
C
[ > About dementia > demonstrated by people with dementia,
Factsheets] and provides suggestions for how to
respond.

Family Caregiver Alliance. Help sheet. Suggests some practical
(2004). Caregivers guide to
understanding dementia
strategies for communicating with people
with dementia and for responding to
G
behaviours. BPSD.
www.caregiver.org
[ > Fact sheets & publications
> Fact sheets > Caregiving
issues & strategies]
CNC Aged Care Royal North Education pack and poster. Primarily
Shore Hospital & Community
Health Services (North
aimed at nurses, this resource uses an
algorithm approach to the assessment and
H
Sydney Health) (2000). management of disturbed behaviour in
Nursing management of older people. Distinguishes between
disturbed behaviour in older delirium, depression, mental disorder and
people in acute care. dementia. Includes copies of tools that
For a copy please contact (02) can be used to assist with the
9926 8705. management of BPSD such as the
Geriatric Depression Scale, behaviour
chart and communication cues sheet. For
the acute sector.
R
people in aged care facilities. dementia. Includes copies of tools that
residential care facilities.
C
people in the community. dementia. Includes copies of tools that
the community sector.

Symbol Explanation
C Community
H Hospital setting
G General
Culturally and linguistically diverse, includes translations
Light reading

Behavioural assessment tools
Introduction
Assessment tools are a method for gathering information that may contribute to
diagnosis, prevention or management. They may include questionnaires, written tests,
checklists and rating scales. In the area of dementia care, there are a great variety of
assessment tools with different properties and different purposes. For example, one
tool may assess depression by observing an individuals behaviour while another may
assess depression by interviewing the person. It is important to understand the
properties of assessment tools:
Validity - does the tool measure what it claims to measure? Does the tool make
sense according to current knowledge on the subject matter?
Reliability - can the tool provide consistent, stable and uniform results over
repeated measurements?
Some tools require specialised training to use, while others rely on families and carers
to provide information. (Refer to Assessment and diagnosis and Guidelines). In
addition, information on assessment in dementia will be available from the following
National Dementia Initiative projects:
Outcome measures suite
Collaborative Dementia Research Centre - Assessment and Better Care Outcomes.
Tools that assess other health issues that may contribute to the behavioural and
psychological symptoms of dementia also need to be considered. For example, tools
to assess depression (for example, the Geriatric Depression Scale - GDS), and anxiety
(for example, the Hospital Anxiety and Depression Scale - HADS) can provide useful
information about psychological health (Refer to Depression assessment).
The following is a brief description of behavioural assessment tools commonly used

when working with people with dementia:
Behavioural Assessment Form (BAF)

There are many examples of assessment tools that use the ABC approach for
documenting changes in behaviour:
A = Antecedent. What happened directly before the behaviour change/incident? Who
was there? Where did the behaviour occur? What else was going on in the location?
B = Behaviour. What exactly was the behaviour? How long did the behaviour last?
What exactly did the person exhibiting the behaviour do and/or say?
C = Consequence. What happened afterwards? What interaction took place with the
person and what else happened?

The Australian Government Department of Health and Ageing recommend the BAF
be completed every time a person living in a residential care facility demonstrates a
significant behavioural change. Carers are encouraged to document what their actions
were and the effect this had on the persons behaviour.
Twenty four hour behaviour time chart

This assessment tool provides an objective structure for documenting behaviours of
concern and their frequency over a 24-hour period. Information gained from the 24-
hour behaviour time chart can be used to identify patterns in behaviour, which can be
used to inform a plan to address the behaviour.
Pooles Algorithm Nursing Management of Disturbed Behaviour

Pooles Algorithm provides information on managing behaviours of concern in older
people in a variety of settings, including acute care, community and residential care.
This assessment tool is designed to encourage consistent and accurate assessment and
management of aggression, delirium, depression or other mental disorders and
dementia.
Dementia Care Mapping

Dementia Care Mapping is an evaluation tool used within a quality improvement
process for the purpose of practice development. It evaluates care from the
perspective of the person with dementia within the framework of person centred care.
The Dementia Care Mapping tool involves structured observation of a number of
people with dementia over a period of time. Four pieces of information are recorded:
What the person is engaged in doing
How they are experiencing this, using levels of mood and engagement as the
gauge for a numerical value
Episodes of interactions that positively support emotional wellbeing
Episodes of interactions that undermine personal sense of value and emotional
wellbeing.
This information is then analysed and interpreted for the purpose of active feedback to
staff in order to improve the quality of care of people with dementia. The process is
the framework for the use of the tool. It involves preparation of staff, feedback to staff
of results and consultation with staff about possible improvements. The process is
repeated to provide comparative data on improvement. Training through an accredited
provider is necessary before the Dementia Care Mapping tool can be implemented.
There are fees associated with the training.

Recommendations
In considering an assessment tool to evaluate behavioural and psychological
symptoms of dementia, the following points should be considered:
Which symptom/s is the target of the assessment?
Who will undertake the assessment (may limit which tools are able to be used)?
How long will be available for the assessment?
Within the above constraints, which of the tools available has adequate reliability
and validity research undertaken in people with cognitive impairment?
If the person to be assessed is from a Culturally or Linguistically Diverse
background, or from an Aboriginal and Torres Strait Islander community, many of
the existing assessment tools will have limitations. Where possible, a tool
developed and validated within the relevant group should be considered (although
there are relatively few of these) (Refer to Assessment and diagnosis).
Substantial research in developing and validating dementia related assessment tools is

needed so that they are appropriate for use with people from Culturally and
Linguistically Diverse backgrounds and Aboriginal and Torres Strait Islander
communities. These tools should address all the important areas related to dementia
care, with the aim of improving wellbeing and outcomes for people with dementia,
their families and carers.
Summary
Assessment tools are important for gaining objective information about behaviours of
concern. It is important to undertake any necessary training for correct understanding
and use of assessment tools.

Behavioural assessment tools

National Dementia Booklet. Developed to assist staff of

Behaviour Advisory
Service. (2003). ReBOC.
respite programs and other carers to
minimise the occurrence and/or reduce the
G
www.alzheimers.org.au impact of behaviours of concern when
[ > SA > Resources > caring for people with dementia. This
ReBOC Reducing resource aims to enhance the
behaviours of concern] communication between respite workers,
For a copy please contact the person with dementia and their family
(08) 8372 2100. members and improve the OH&S of
people who provide respite.
CNC Aged Care Royal Education pack and poster. Primarily

North Shore Hospital &
Community Health Services
H
(North Sydney Health) management of disturbed behaviour in
(2000). Nursing older people. Distinguishes between
management of disturbed delirium, depression, mental disorder and
behaviour in older people in dementia. Includes copies of tools that can
acute care. be used to assist with the management of
For a copy please contact BPSD such as the Geriatric Depression
(02) 9926 8705. Scale, behaviour chart and communication
cues sheet. For the acute sector.

R
aged care facilities. be used to assist with the management of
cues sheet. For residential care facilities.

C
the community. be used to assist with the management of
cues sheet. For the community sector.
Australian Government Website. Contains a range of resources to

Department of Health and
Ageing. (2005). NatFrame
support documentation and use of
appropriate assessment tools in residential
R
(previously known as the care, with a focus on tools relevant for
Draft National Framework people with cognitive impairment.
for Documenting Care in
Residential Aged Care
Services).
www.health.gov.au
[ > For health professionals
> Aged care > Publications
> Natframe]
Dementia Care Mapping. Refer to description in Behavioural

www.brad.ac.uk/acad/health
[ > Bradford dementia group
assessment tools. Training in Dementia
Care Mapping is available from Bradford
G
> Dementia care mapping] Dementia Group approved trainers who
have extensive practice and experience in
the application of this tool. In Australia
the Dementia Education and Training
Institute Australia (DTIA) coordinates this
training. There are fees associated with
participating in the training. The
Alzheimers Australia website may have
information on local courses:
www.alzheimers.org.au.

Symbol Explanation
C Community
H Hospital setting
G General
Light reading

Responding to symptoms and behaviours
Introduction
Changes in the behaviour of the person with dementia can be challenging for both the
person with dementia, and for their families and carers. There are many reasons why
behaviour may change and it is important to understand that the behaviours are not
deliberate. Dementia is a result of changes in the brain that affect a persons memory,
mood and behaviour. Sometimes the behaviour may be a result of these changes in the
brain. Other times, the persons environment or physical health may trigger the
behaviour. It is important to try and understand why the person with dementia may be
behaving in a particular way. If families and carers can determine what may be
triggering the behaviour, it may be easier to figure out ways to minimise or prevent
the behaviour happening again.
Sometimes medication may be used to treat psychiatric symptoms or psychiatric

disorders, or to reduce behaviours of concern. However, not all behaviours are helped
by medication, and it is best used in conjunction with other strategies (Refer to
Medical treatment options).
Recommendations
A range of approaches and strategies can be used to modify or change behaviours and
psychological symptoms associated with dementia so that quality of life may be
improved. It is also important for families and carers to seek assistance and ensure
that they have support and adequate breaks.
Families and carers may find the following strategies helpful when responding to the
behavioural and psychological symptoms of dementia:
Look for patterns in the behaviour, and try to identify any triggers. Certain
behaviours may only be displayed at certain times, or during particular activities.
Consider the effect of the environment, such as bright lights and noise from the
television or radio, as these may add to confusion, agitation, or restlessness.
Establish a routine. Familiar surroundings are important for people with dementia,
and help promote orientation and feelings of security. The person with dementia
may become upset if they find themselves in a strange situation or among
unfamiliar people, and may become confused, anxious, or agitated (Refer to
Quality care).
Clear and simple communication is important. The person with dementia may
become agitated if they do not understand what is expected of them. They may
also feel frustrated with their inability to make them self understood. It is
important to face the person, speak slowly in a calm and reassuring voice and use
simple sentences. Be patient and allow extra time (Refer to Communication).

Ensure the person with dementia participates as much as possible in daily
activities. Make sure the task isnt too complicated or the person with dementia
may become overwhelmed.
Regular exercise is important. Simple exercise, like a walk outside or a game, can
reduce anxiety and depression and can minimise other behaviours such as
wandering and restlessness (Refer to Physical activity and exercise).
Distraction often helps. If possible, direct the person with dementia away from a
particular task or environment that seems to be triggering the behaviour. Suggest a
different activity that the person with dementia may like, such as listening to a
favourite song, or going outside.
Avoid punishment. The person with dementia may not remember the event, and
therefore may not be able to learn from it. Try to stay positive.
Be consistent. If there are strategies for modifying behaviours that work, try to
ensure other people who also care for the person with dementia use the same
strategies.
It may be necessary to experiment with different strategies at different times to meet

the changing needs of the person with dementia. However, it is not always possible to
treat, prevent, reduce, or change behaviours. Concentrate on handling the situation as
calmly and effectively as possible. Try to be realistic about goals, and work towards
improving the quality of life of the person with dementia. It also is important for
families and carers to take care of themselves. Do not feel guilty if frustrated or angry
with the person with dementia or with the situation, but do seek extra support. Talk to
your doctor, a friend, or a counsellor. Remember to take adequate breaks from caring.
Who can help?

Discuss behaviours of concern and their impact with a doctor or health
professional. The doctor will be able to check whether there is a physical illness or
discomfort present that may be triggering the behaviour, and can assess any
medication needs.
The National Dementia Behaviour Advisory Service (NDBAS) is a national
telephone advisory service for families, carers, and respite staff who are concerned
about the behaviours of people with dementia. The service is confidential, and
provides comprehensive advice 24 hours a day, 7 days a week. Contact NDBAS
on 1300 366 448.
Summary
Coping with the changed symptoms and behaviours that may occur with dementia are
among the most difficult aspects of caring for a person with dementia. In many
instances there are strategies that can help if triggers for the symptoms or behaviours
are identified. Where these approaches are not successful, medication treatment may
be required.

Responding to symptoms and behaviours

General resources
Alzheimers Australia. Help sheet. Briefly describes some of the
(2005). Help sheet 1.9:
Drug treatments and
common medications used to treat BPSD
and co morbidities such as depression,
C
dementia. anxiety, and sleep disturbance. Lists
www.alzheimers.org.au questions carers may ask a doctor about
[ > Publications & resources medications for people with dementia.
> Helpsheets & update
sheets > About dementia]
Alzheimers Australia. Help sheet. Briefly describes some

(2005). Help sheet 5.1:
Changed behaviours.
common behaviour changes that may
occur in people with dementia. Also
G
www.alzheimers.org.au provides some general guidelines for
[ > Publications & resources coping with changed behaviours.
> Helpsheets & update
sheets > Changed
behaviours and dementia]
Alzheimer's Society (UK). Website. As dementia develops, it can

(2008). Unusual behaviour.
www.alzheimers.org.uk
cause behavioural changes. This website
explains behaviours commonly
C
[ > About dementia > demonstrated by people with dementia,
Factsheets] and provides suggestions for how to
respond.

Alzheimer Society of Canada. Manual. Designed for staff and
(2004). Search is an
emergency.
management in residential care facilities
and hospitals. Includes information
H
www.alzheimer.ca regarding planning and preparing for a
[ > Quick links > Download search for someone with dementia who R
brochures > Other is missing. Contains some Canadian
publications] specific information.
Bonner, C. (2005). Reducing Book. Primarily directed towards staff

stress-related behaviours in
people with dementia: Care-
in residential care facilities, but may
also be relevant to community settings.
R
based therapy. London: Jessica Focuses on the concept of a
Kingsley Publishers. progressively lowered stress threshold in
ISBN: 1843103494 Alzheimers disease. Discusses stress
factors and provides practical examples
of ways to prevent and minimise stress
in people with dementia.
Resources related to specific behaviours
Alzheimers Australia. (2005). Help sheet. Provides a brief summary of
Help sheet 5.3: Depression
and dementia.
the signs of depression such as lack of
energy, poor sleep and loss of appetite.
G
www.alzheimers.org.au Suggests some strategies to assist with
[ > Publications & resources > the management of depression,
Helpsheets & update sheets > including medication/medical
Changed behaviours and interventions.
dementia]
Alzheimers Australia. (2005). Help sheet. Discusses possible factors

Help sheet 5.4: Wandering.
www.alzheimers.org.au
contributing to a person with dementia
wandering such as loss of memory,
G
[ > Publications & resources > excess energy and boredom. Provides a
Helpsheets & update sheets > range of strategies to try to reduce
Changed behaviours and wandering behaviour.
dementia]
Alzheimers Australia. (2005). Help sheet. Discusses possible factors

Help sheet 5.5: Sundowning.
contributing to a person with dementia
becoming restless and/or agitated in the
G
[ > Publications & resources > afternoon or evening. Includes some
Helpsheets & update sheets > strategies to help with the management
Changed behaviours and of sundowning.
dementia]

Alzheimers Australia. (2005). Help sheet. Discusses the causes of
Help sheet 5.6: Anxious
behaviours.
anxious behaviours in people with
dementia including changes in the brain,
G
www.alzheimers.org.au grief and fear of failure. Suggests some
[ > Publications & resources > ways to effectively manage anxious
Helpsheets & update sheets > behaviours. Also includes some sources
Changed behaviours and of additional help.
dementia]
Alzheimers Australia. (2005). Help sheet. Discusses possible causes of

Help sheet 5.7: Aggressive
behaviours.
aggressive behaviour in people with
dementia including health factors, the
G
www.alzheimers.org.au environment and/or the task. Suggests
[ > Publications & resources > some ways to manage and some sources
Helpsheets & update sheets > of help.
Changed behaviours and
dementia]
Alzheimers Australia. (2005). Help sheet. Describes some of the

Help sheet 5.8: Agitated
behaviours.
common causes of agitation, including
health problems, sense of failure,
G
www.alzheimers.org.au misunderstanding, fear, and seeking
[ > Publications & resources > attention. Suggests some strategies to
Helpsheets & update sheets > help reduce agitation.
dementia]
Alzheimers Australia. (2005). Help sheet. Describes some of the

Help sheet 5.9: Hallucinations
and false ideas.
common causes of hallucinations and
false ideas such as health factors, new
G
www.alzheimers.org.au environments and sensory overload.
[ > Publications & resources > Suggests some strategies to assist family
Helpsheets & update sheets > and carers to with coping with
Changed behaviours and hallucinations and false ideas.
dementia]
Alzheimers Australia. (2005). Help sheet. Defines disinhibition and

Help sheet 5.10: Disinhibited
behaviours
describes some of the common causes of
disinhibited behaviours such as
G
www.alzheimers.org.au confusion and loss of skills. Suggests
[ > Publications & resources > some strategies to try, as well as some
Helpsheets & update sheets > sources of help.
dementia]

Alzheimer's Association Guidelines. Provides strategies for
(USA). (2006). Dementia care
practice recommendations for
quality residential care using evidence-
based principles, including strategies for
R
assisted living residences and responding to people with dementia who
nursing homes. may wander. This information may be
www.alz.org particularly useful for staff in residential
[ > Professionals & researchers aged care facilities.
> Professional care providers >
Residential care > Quality care
campaign > Care practices >
Dementia care practice
recommendations: Phase 1 and
2]
Futrell, M., & Melillo, K.D. Booklet. Concise document with

(2002). Evidence-based
protocol: Wandering. Iowa
evidence-based recommendations for
addressing wandering in people with
H
City: University of Iowa cognitive impairment in health services
Gerontological Nursing or residential care facilities. Includes R
Interventions Research Centre. recommended screening and assessment
www.nursing.uiowa.edu tools and procedures, and considers
Available for purchase through environmental modifications,
University of Iowa College of technology and safety, physical and
Nursing. psychosocial interventions, and staff
[ > Products & services > EBP support and education.
guidelines]
Bottrill, P., & Mort, F. (2003). Discussion paper. Reviews the limited
For Alzheimers Australia
(SA). Rethinking dementia and
literature available specifically on
dementia and abuse, and explores the
G
aggression: A discussion incidence, and historical and theoretical
paper drawing on insights perspectives of abuse and violence
from domestic violence and where dementia is a significant factor.
elder abuse perspectives.
[ > Publications & resources >
Issues papers > Elder abuse
papers]

Livingstone, G., Johnston, K., Journal article. A systematic review of
Katona, C., Paton, J., &
Lyketsos, C.G. (2005).
research regarding psychological
approaches to treating the
G
Systematic review of neuropsychiatric symptoms of dementia.
psychological approaches to
the management of
neuropsychiatric symptoms of
dementia. American Journal of
Psychiatriy, 162(11), 1996-
2021.
www.ajp.psychiatryonline.org
[ > Past issues > 2005 >
November 2005]
McGonigal-Kenney, M.L., & Guidelines. Detailed information on

Schutte, D.L. (2004). Non-
pharmacologic management of
agitated behaviours in people with
dementia and non-pharmacologic
H
agitated behaviors in persons strategies commonly used.
with Alzheimer disease and R
other chronic dementing
conditions. Iowa City:
University of Iowa
Gerontological Nursing
Interventions Research Center,
Research Dissemination Core.
www.nursing.uiowa.edu
Available for purchase through
University of Iowa College of
Nursing.
[ > Products & services > EBP
guidelines]
Postgraduate Medicine Special Guidelines. Detailed information on the

Report. (2005). Treatment of
dementia and agitation: A
common triggers for agitation in the
person with dementia. Provides an
G
guide for families and extensive range of suggested strategies
caregivers. to reduce agitation, including
www.psychguides.com modification of the environment,
[ > Patient- family guides] changing supervision of activities,
changing communication strategies and
medications. Written primarily for
families and carers.
UK Wandering Network Website. This website provides
(UKWN). (2009). UK
Wandering Network.
information and resources in relation to
wandering, one of the symptoms of
G
http://wanderingnetwork.co.uk dementia.

Symbol Explanation
C Community
H Hospital setting
G General
Culturally and linguistically diverse, includes translations
Light reading

Alternative and complementary therapies
Introduction
Alternative and complementary therapies are often used in addition to medical
treatments to manage the behavioural and psychological symptoms of dementia. Some
forms of alternative and complementary therapies used for dementia include
acupuncture, aromatherapy, bright light therapy, dietary supplements, herbal
medicine, massage, music therapy, reminiscence, and validation therapy. Different
therapies may help manage different symptoms or behaviours.
Recommendations
It is important to be aware that the effectiveness of many alternative and
complementary therapies has not been researched extensively. However, many
families and carers find alternative and complementary therapies of benefit to the
person with dementia.
The following is a brief list of strategies that families and carers may find helpful in
managing the behavioural and psychological symptoms of dementia.
Communication is important. Always explain to the person with dementia what is
going to happen. Speak slowly in a calm and reassuring voice, and use simple
sentences. Be patient.
Involve the person with dementia as much as possible. Even if the person with
dementia cannot participate verbally, they can still enjoy certain activities, such as
reminiscing about their past by looking at old photos, or listening to a favourite
song.
Be sensitive to the reactions of the person with dementia. Therapies that involve
remembering about the past, such as reminiscence or music therapy, may prompt
happy memories, but may also prompt painful or sad memories.
Avoid creating discomfort for the person with dementia. Sometimes the person
with dementia may not feel comfortable being touched, so therapies such as
massage may not be appropriate for these people.
Discuss complementary therapies with a doctor or health professional. Some
dietary supplements or herbal medicines may react with other medications so it is
important that the doctor is aware of all types of treatments and therapies used.
It may be necessary to try different approaches at different times to meet the changing
needs of the person with dementia. It is useful to find out what the person used to
enjoy i.e., previous hobbies, interests, music, routines, and try to incorporate some of
these in to activities. Try to be realistic about goals and work towards improving the
quality of life of the person with dementia.

Summary
There are a variety of alternative or complementary approaches available that may be
benefit people with dementia. As with all forms of treatment, it is advisable to seek
out as much information as possible about each approach before making a decision to
try them.

Alternative and complementary therapies

Alzheimers Australia. (2005). Help sheet. Describes three

Help sheet 2.2: Therapies and
communication approaches.
approaches to communication with
people in dementia: Validation
C
www.alzheimers.org.au Therapy, Music Therapy and
[ > Publications & resources > Reminiscence.
Helpsheets & update sheets >
Caring for someone with
dementia]
Alzheimer's Society. (2003). Help sheet. Outlines evidence for the

Complementary and alternative
medicine and dementia.
effectiveness of some commonly
used complementary and alternative
C
www.alzheimers.org.uk treatments for dementia.
[ > About dementia > Fact sheets]
OConnor, D., & Ames, D. Research summary. A brief summary

(2008). Consumer summary -
Behavioural and psychological
of psychosocial treatments for
dementia. Designed for people with
C
symptoms of dementia: A dementia and their families and
literature review of psychosocial carers.
treatments and the identification
of further research topics
regarding treatment effectiveness
and implementation.
www.dementia.unsw.edu.au
[ > Research > Research about
assessment and better care
outcomes > Behavioural and
psychological symptoms of
dementia]

OConnor, D., & Ames, D. Research summary. A brief summary
(2008). Tips for clinicians - of psychosocial treatments for
Behavioural and psychological dementia. Designed for health R
symptoms of dementia: A professionals.
literature review of psychosocial
treatments and the identification
of further research topics
regarding treatment effectiveness
and implementation.
www.dementia.unsw.edu.au
[ > Research > Research about
assessment and better care
outcomes > Behavioural and
psychological symptoms of
dementia]
The Benevolent Society. (2005). Booklet. Outlines reminiscing

Reminiscing handbook.
www.bensoc.org.au
therapy and the potential benefits for
older people, either within structured
G
[ > Resources > Search] group sessions, one-on-one sessions,
or in everyday interactions.
Birks, J., & Grimley Evans, J. Journal article. Reviews the evidence
(2007). Ginkgo biloba for
cognitive impairment and
on the efficacy and safety of Ginkgo
biloba for the treatment of dementia
C
dementia. Cochrane Database of or cognitive decline. The authors
Systematic Reviews. conclude that there is no convincing R
www.mrw.interscience.wiley.com evidence that Ginkgo biloba is
[ > Search: publication titles efficacious for dementia and
Cochrane > The Cochrane cognitive impairment.
library 2007 > Search: article title
> Select Record for full text]
Chung, JCC. & Lai, CKY. Journal article. Reviews the evidence
(2002). Snoezelen for dementia.
Cochrane Database of Systematic
on the effectiveness of Snoezelen in
the management of BPSD. The
C
Reviews. authors found there were no RCTs
www.mrw.interscience.wiley.com supporting the effectiveness of R
[ > Search: publication titles Snoezelen for people with dementia.
Cochrane > The Cochrane The authors did note a need for better
library 2007 > Search: article title quality research in this area.

Clare, L., & Woods, RT. (2003). Journal article. Reviews the evidence
Cognitive rehabilitation and
cognitive training for early-stage
for cognitive rehabilitation and
training in early-stage dementia. The
C
Alzheimers disease and vascular authors conclude there is no evidence
dementia. Cochrane Database of for the efficacy of cognitive training, R
Systematic Reviews. and insufficient evidence to evaluate
www.mrw.interscience.wiley.com individualised cognitive rehabilitation,
[ > Search: publication titles in improving cognitive functioning for
Cochrane > The Cochrane people with mild to moderate
library 2007 > Search: article title Alzheimers disease or Vascular
> Select Record for full text] dementia.
Draper, B. (2004). Dealing with Book. A comprehensive and accessible

dementia: A guide to Alzheimers
disease and other dementias.
guide to understanding dementia for
families and carers. Includes practical
G
Crows Nest: Allend & Unwin. information on assessment and
ISBN: 1865088536 diagnosis, medical treatment options,
complementary therapies, and
residential and respite care.
Forbes, D., Morgan, DG., Journal article. Reviews the evidence
Bangma, J., Peacock, S., &
Adamson, J. (2004). Light
for light therapy treatment in the
management of sleep, behaviour and
C
therapy for managing sleep, mood disturbances in dementia. The
behaviour, and mood disturbances authors conclude there is insufficient R
in dementia. Cochrane Database evidence to assess this treatment and
of Systematic Reviews. the available studies are of poor
www.mrw.interscience.wiley.com quality and further research is
[ > Search: publication titles required.
Cochrane > The Cochrane
Hermans, DG., Htay, U Hla., & Journal article. Reviews the

McShane, R. (2004). Non-
pharmacological interventions for
effectiveness and safety of non-
pharmacological interventions in
C
wandering of people with reducing wandering in the domestic
dementia in the domestic setting. setting in people with dementia. The R
Cochrane Database of Systematic authors conclude that there was no
Reviews. evidence of the efficacy of this
www.mrw.interscience.wiley.com treatment due to lack of trials.
[ > Search: publication titles

Mccarney, R., Warner, J., Fisher, Journal article. Reviews the evidence
P., & Van Haselen, R. (2003).
Homeopathy for dementia.
of homeopath treatments for dementia.
The authors conclude that there is no
C
Cochrane Database of Systematic evidence that homeopathy is effective
Reviews. in treating dementia. R
www.mrw.interscience.wiley.com
Neal, M., Barton Wright, P. Journal article. Reviews the evidence

(2003). Validation therapy for
dementia. Cochrane Database of
for validation therapy as a treatment
for dementia. Validation therapy is the
C
Systematic Reviews. acceptance of the reality and personal
www.mrw.interscience.wiley.com truth of anothers experience and R
[ > Search: publication titles incorporates a range of specific
Cochrane > The Cochrane techniques. The authors report that
library 2007 > Search: article title there is insufficient evidence to allow
> Select Record for full text] any conclusion about the efficacy of
this therapy.
Peng, WN., Zhao, H., Liu, ZS., & Journal article. Reviews the evidence
Wang, S. (2007). Acupuncture for
vascular dementia. Cochrane
for acupuncture as a treatment for
Vascular dementia. The authors
C
Database of Systematic Reviews. conclude that the effectiveness of
www.mrw.interscience.wiley.com acupuncture for Vascular dementia is R
[ > Search: publication titles uncertain and that more evidence is
Cochrane > The Cochrane required.
Price, JH., Hermans, DG., Journal article. Reviews the evidence

Grimley Evans, J. (2001).
Subjective barriers to prevent
for subjective barriers (patterns on
floors, doorknobs etc) as a
C
wandering of cognitively preventative measure for wandering in
impaired people. Cochrane people with cognitive impairment. R
Database of Systematic Reviews. The authors conclude that there is no
www.mrw.interscience.wiley.com evidence that subjective barriers
[ > Search: publication titles prevent wandering.

Thorgrimsen, L., Spector, A., Journal article. Reviews the evidence
Wiles, A., & Orrell, M. (2003).
Aromatherapy for dementia.
for aromatherapy as a treatment for
dementia. The authors conclude that
C
Cochrane Database of Systematic aromatherapy does show benefit for
Reviews. people with dementia but more well R
www.mrw.interscience.wiley.com designed research is needed.
Viggo Hansen, N., Jorgensen, T., Journal article. Reviews the evidence
& Ortenbald, L. (2006). Massage
and touch for dementia. Cochrane
for massage and touch in the treatment
of dementia. The authors conclude that
C
Database of Systematic Reviews. more research is needed to provide
www.mrw.interscience.wiley.com definitive evidence about the benefits R
[ > Search: publication titles of this therapy.
Vink, AC., Birks, JS., Bruinsma, Journal article. Reviews the evidence
MS., & Scholten, RJPM. (2006).
Music therapy for people with
for music therapy as a treatment for
dementia. The authors conclude that
C
dementia. Cochrane Database of the methodological quality and the
Systematic Reviews. reporting of the included studies were R
www.mrw.interscience.wiley.com too poor to draw any useful
[ > Search: publication titles conclusions.
Woods, B., Spector, A., Jones, C., Journal article. Reviews the evidence
Orrell, M., & Davies, S. (2006).
Reminiscence therapy for
for reminiscence therapy as a treatment
for dementia. Reminiscence therapy
C
dementia. Cochrane Database of (RT) involves the discussion of past
Systematic Reviews. activities, events and experiences with R
www.mrw.interscience.wiley.com another person or group of people,
[ > Search: publication titles usually with the aid of tangible
Cochrane > The Cochrane prompts, such as photographs.
library 2007 > Search: article title Participants are encouraged to talk
> Select Record for full text] about past events at least once a week.
RT is one of the most popular
psychosocial interventions in dementia
care. The authors report there is
inconclusive evidence of the efficacy
of RT for dementia.

Symbol Explanation
C Community
G General
Light reading


Behavioural & Psychological Symptoms

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Behavioural and psychological symptoms of dementia

Behavioural and psychological symptoms of dementia 7.01

It is difficult to estimate the rate of BPSD as different symptoms occur during

Behavioural and psychological symptoms of dementia 7.02

What do you mean, hes usually so polite, asked Menka.

Behavioural and psychological symptoms of dementia 7.03

There is always a cause for behaviour, whether or not it is related to dementia.

Behavioural and psychological symptoms of dementia 7.04

Name of resource and Brief description and type of Target

Family Caregiver Alliance. Help sheet. Provides some practical

Fearnley, K. (2006). For Booklet. Information and advice for

Mace, N.L., & Rabins, P.V. Book. A comprehensive resource for

Behavioural and psychological symptoms of dementia 7.05

Scottish Intercollegiate Guidelines. Detailed evidence-based

R Residential care setting

Medium level resource

In depth, detailed resource

Underlined text Refer to glossary for definition

Behavioural and psychological symptoms of dementia 7.06

Some of the factors that may contribute to BPSD are as follows:

Families and carers:

Behavioural and psychological symptoms of dementia 7.08

Behavioural and psychological symptoms of dementia 7.09

Name of resource and Brief description and type of Target

Alzheimers Australia. DVD or VHS. An audiovisual resource

Alzheimers Australia. Help sheet. Describes a range of potential

Alzheimer's Society (UK). Website. As dementia develops, it can

Behavioural and psychological symptoms of dementia 7.10

Behavioural and psychological symptoms of dementia 7.11

R Residential care setting

Culturally and linguistically diverse, includes translations

Medium level resource

In depth, detailed resource

Underlined text Refer to glossary for definition

Behavioural and psychological symptoms of dementia 7.12

The following is a brief description of behavioural assessment tools commonly used

Behavioural Assessment Form (BAF)

Behavioural and psychological symptoms of dementia 7.13

Twenty four hour behaviour time chart

Pooles Algorithm Nursing Management of Disturbed Behaviour

Dementia Care Mapping

Behavioural and psychological symptoms of dementia 7.14

Substantial research in developing and validating dementia related assessment tools is

Behavioural and psychological symptoms of dementia 7.15

Name of resource and Brief description and type of Target

National Dementia Booklet. Developed to assist staff of

CNC Aged Care Royal Education pack and poster. Primarily

CNC Aged Care Royal Education pack and poster. Primarily

Behavioural and psychological symptoms of dementia 7.16

Australian Government Website. Contains a range of resources to

Dementia Care Mapping. Refer to description in Behavioural

Behavioural and psychological symptoms of dementia 7.17

R Residential care setting

Medium level resource

In depth, detailed resource

Underlined text Refer to glossary for definition

Behavioural and psychological symptoms of dementia 7.18

Sometimes medication may be used to treat psychiatric symptoms or psychiatric

Behavioural and psychological symptoms of dementia 7.19

It may be necessary to experiment with different strategies at different times to meet

Who can help?

Behavioural and psychological symptoms of dementia 7.20

Name of resource and Brief description and type of Target