Behavioral and psychological symptoms of dementia (BPSD) — agitation, aggression, psychosis, depression, anxiety, apathy, sleep disturbance, wandering, repetitive behaviors — affect up to 90% of dementia patients across the disease course and drive much of the care burden, caregiver stress, placement decisions, and medication use. The longevity-psychiatry frame treats BPSD seriously as both a quality-of-life concern and a clinical entity that can be substantively managed, with the discipline of trying non-pharmacological approaches first and using pharmacology with care.
The prevalence and trajectory. Most dementia patients experience BPSD at some point. Specific symptoms vary by stage and dementia type — depression and anxiety often early, agitation and psychosis often middle stages, apathy across the course, wandering and motor symptoms variable. The temporal pattern matters for clinical planning; understanding the trajectory helps anticipate and address symptoms.
The dementia-type specific patterns. Alzheimer's disease: gradual progression with depression and anxiety early, agitation and psychosis middle stages. Lewy body dementia: prominent visual hallucinations, REM behavior disorder, fluctuating cognition. Frontotemporal dementia: behavioral disinhibition, apathy, social conduct changes early. Vascular cognitive impairment: stepwise progression, mood symptoms common. The pattern recognition guides differential and treatment.
The clinical approach framework. Non-pharmacological interventions first — environmental modifications, caregiver education, validated behavioral approaches, addressing unmet needs (pain, hunger, infection, fear). Pharmacological interventions when behavioral approaches are inadequate, with attention to specific symptoms rather than generic sedation. Distinct symptoms warrant distinct approaches — agitation, psychosis, depression, anxiety each have specific evidence-based interventions (covered in subsequent stages).
The longitudinal care frame. BPSD changes over disease course; the treatment plan evolves accordingly. Caregiver support is central — caregiver burden directly affects patient care quality. Advance care planning conversations address BPSD scenarios where decisions about treatment intensity, hospitalization, and comfort care become relevant. The integrated longitudinal care produces better outcomes than episode management. The discipline is to engage BPSD as substantive clinical territory deserving serious attention, use non-pharmacological approaches first, treat specific symptoms with specific evidence-based approaches, and integrate with longitudinal dementia care.