Behavioural and psychological symptoms of dementia
Help for the distress, agitation and changes in behaviour that can come with dementia, looking first for causes and trying non-drug approaches before medicines.
✓ Medically reviewed by a GMC-registered consultant · last reviewed September 2026 · next review September 2027 · how we review
In short
- These behaviours are usually distress or an unmet need being communicated — the first step is to look for a cause such as pain, infection or constipation.
- Non-drug, person-centred approaches are tried first and help many people, without medication risk.
- Antipsychotic medicines carry an increased risk of stroke and death in dementia and are a last resort — lowest dose, shortest time, with review and a plan to stop.
- A sudden change in behaviour may be delirium and is a medical emergency that needs urgent assessment, not simply more sedation.
A plain-English summary. The detail — including risks and recovery — is below.
At a glance
A general guide. Your psychiatrist will give you advice for your situation.
Can reduce distress, agitation and fear, improving comfort and dignity.
Medicines are not the right first response for most BPSD; for many people non-drug approaches are more appropriate and safer.
Urgent or obvious causes (such as pain, infection or constipation) are treated, and non-drug approaches are put in place and shared with carers.
A written, person-centred care plan shared with everyone involved.
Urgent or obvious causes (such as pain, infection or constipation) are treated, and non-drug approaches are put in...
The plan is reviewed to see what is helping. Triggers are refined and approaches adjusted; consistency matters...
Response and side effects are watched closely, the lowest helpful dose is used, and a review date is set with the...
Regular reviews check whether treatment is still needed and still safe, and adapt the plan as the dementia and the...
What are behavioural and psychological symptoms of dementia?
As dementia progresses, many people experience changes that are often more distressing than memory loss itself: agitation, restlessness, anxiety, low mood, sleep disturbance, suspicion, seeing or hearing things that are not there, calling out, resisting care, or becoming withdrawn. These are grouped together as behavioural and psychological symptoms of dementia (BPSD).
These symptoms are usually the person's way of communicating an unmet need or distress — pain, infection, hunger, thirst, constipation, fear, boredom, too much noise, or not understanding what is happening. The first and most important step is to look for and treat a cause, especially a sudden change, which may be delirium rather than the dementia itself.
The recommended approach is to try non-drug, person-centred approaches first: understanding triggers, adjusting the environment, reassurance, routine, activity and good communication. These work for many people and carry no medication risk.
Medicines, particularly antipsychotics, are a last resort for most symptoms. In people with dementia they carry a recognised increased risk of stroke and death, so they are used only for severe distress or risk, at the lowest dose, for the shortest time, with clear review. This guide explains how the symptoms are understood and managed, not how to push any one treatment.
Types, options & approaches
There may be different ways to do this. The right approach depends on the clinical question and your circumstances.
Non-drug approaches versus antipsychotic medicines
| Aspect | Non-drug first | Antipsychotic medicine |
|---|---|---|
| When used | First, for most symptoms | Last resort, severe distress or risk |
| Main risks | Few; needs time and consistency | Increased stroke and death risk, sedation, falls |
| Duration | Ongoing part of care | Lowest dose, shortest time, reviewed |
| Addresses cause? | Often, by finding triggers | Masks symptoms, not the cause |
Medicines are sometimes necessary for safety, but they should add to — not replace — efforts to find the cause and support the person.
Preparing for your treatment
- Keep a simple diary of what happens before, during and after episodes — time of day, who was there, and possible triggers.
- Note any signs of pain, infection, constipation, poor sleep, hunger or thirst, which are common hidden causes.
- Bring a full list of all medicines, including any recently started, stopped or changed.
- Share the person's life history, routines, likes and dislikes — these guide the most effective support.
- Tell the clinician about any sudden change, as this may be delirium needing urgent assessment.
- Be ready to discuss the impact on you as a carer, and what support you have.
- Think about what you hope treatment will achieve, and what trade-offs you would and would not accept.
What happens
A clinician — often a GP, memory service or old age psychiatrist — will take time to understand the behaviour: what it looks like, when it happens, what seems to trigger it, and how it affects the person and those around them. They will check carefully for treatable causes such as pain, infection, constipation, medication side effects or delirium.
They will usually start with person-centred, non-drug approaches tailored to the individual, and support carers or care staff to use them consistently. The plan is reviewed to see what helps.
If symptoms are severe, persistent or pose a risk, and other approaches have not worked, medicines may be discussed. Any antipsychotic is started at the lowest dose for the shortest time, with the risks of stroke and death explained, a clear target, and a planned review with the intention of stopping. Throughout, the aim is comfort, dignity and safety, not simply calming the person down.
Is this treatment right for me?
A good consultation should explore whether it's the right choice for you now — including reasons to wait or consider something else.
May not be suitable if…
- Medicines are not the right first response for most BPSD; for many people non-drug approaches are more appropriate and safer.
- Antipsychotics are generally unsuitable for mild agitation, wandering, calling out or sleep problems alone, where the risks outweigh the benefits.
- Antipsychotics must be used with great caution, or avoided, in Lewy body dementia because of severe sensitivity reactions.
- Treating behaviour as 'just the dementia' is the wrong approach when a sudden change suggests delirium or untreated pain.
Delay or rearrange if…
- There is a sudden change suggesting delirium — assess and treat that urgently first.
- Pain, infection, constipation or a recent medication change has not yet been looked for and treated.
- Non-drug approaches have not yet been tried or given a fair chance, unless there is immediate risk.
- The diagnosis or type of dementia is unclear and would change which medicines are safe.
Alternatives to discuss
- Person-centred, non-drug approaches as the mainstay for most symptoms.
- Treating underlying physical causes such as pain, infection or constipation.
- Reviewing and reducing medicines that may be contributing to confusion or agitation.
- Support, training and respite for carers and care staff.
- Specific treatment of clear depression or anxiety, with monitoring, where present.
Before you decide
Use this as a shared-decision checklist. The aim is not just “can this be done?”, but whether it is right for you, now, with the risks and alternatives clearly understood.
What matters most to me?
Think about symptoms, daily life, work, caring responsibilities, sport, fertility, travel, appearance and anxiety — the right choice depends on your priorities, not just the medical facts.
What are all my options?
Ask about waiting, monitoring, medicines, rehabilitation, a smaller or larger procedure, a different test, NHS referral, or a second opinion where that would help.
What would make me pause?
Active infection, pregnancy, unstable medical problems, smoking, medicines that increase bleeding, poor support at home, or feeling pressured are all reasons to slow down and get tailored advice.
What happens if I do nothing today?
For some problems, waiting is safe; for others, delay can make treatment harder. A good consultation should explain the trade-off in plain English.
Benefits
- Can reduce distress, agitation and fear, improving comfort and dignity.
- Finding a hidden cause such as pain or infection can resolve the behaviour without medicines.
- Person-centred approaches can improve quality of life with little or no risk.
- Better understanding and support can ease the strain on carers and care staff.
- Careful review reduces the chance of harmful or unnecessary long-term medication.
Risks & complications
- Approaches take time, patience and consistency, and what works can change as dementia progresses.
- Sedating medicines can cause drowsiness, unsteadiness and falls.
- Symptoms may partly improve rather than disappear, which can be frustrating.
- Over-the-counter or 'as needed' sedatives can build up and worsen confusion.
- Medicines being continued longer than intended without review.
- Side effects such as stiffness, restlessness or worsened swallowing from antipsychotics.
- A treatable cause being missed because behaviour is assumed to be 'just the dementia'.
- Stroke and increased risk of death linked to antipsychotic use in dementia.
- Serious medication reactions, including in people with Lewy body dementia who can be very sensitive to antipsychotics.
The central issue is that antipsychotic medicines increase the risk of stroke and death in people with dementia, so they are a last resort and must be reviewed and stopped where possible. People with Lewy body dementia can react severely to these medicines. Equally important is not missing a sudden, treatable cause such as delirium. Ask why a medicine is being suggested, what the target is, when it will be reviewed, and what non-drug steps have been tried.
Published figures to discuss
Large reviews show antipsychotics increase the risk of stroke and death in people with dementia, but the exact size of the risk varies with the drug, dose, duration and the individual, and absolute numbers differ between studies. Benefits for agitation are modest at best. We have therefore described the risk in clear qualitative terms rather than quoting a single precise figure, and the prescribing decision must weigh this individually.
| Figure | Reported range | How to interpret it | Source / confidence |
|---|---|---|---|
| Delirium, pain or infection missed | Common reversible trigger | Sudden behaviour change in dementia should prompt assessment for delirium, pain, constipation, urinary retention, infection and medicines. | NICE NG97 — Dementia: assessment, management and supportnice.org.ukSource-linked context |
| Antipsychotic harms | Higher in dementia | Antipsychotics can increase sedation, falls, stroke and mortality risk and should be time-limited and reviewed. | NICE NG97 — Dementia: assessment, management and supportnice.org.ukSource-linked context |
| Carer injury or burnout | Common in severe distress/aggression | Risk plans should include the carer's safety, respite and crisis contacts. | NICE NG97 — Dementia: assessment, management and supportnice.org.ukSource-linked context |
| Non-drug causes ignored | Common pitfall | Noise, overstimulation, unmet needs, communication difficulty, sleep, loneliness and routine changes often drive distress. | Guide sourcesClinical context |
These are literature figures, not a personalised prediction. Your own risks and likely benefits depend on your circumstances, your health, and how your care is carried out and followed up.
What happens afterwards
This is ongoing management rather than a one-off treatment, so 'afterwards' means how symptoms respond over time and how the plan is reviewed and adjusted.
- Gradual, partial improvement rather than a sudden fix.
- Symptoms that vary day to day and are often worse in the evening.
- Needing to try and adjust several approaches before finding what helps.
- Some tiredness or quietness if a sedating medicine is used, prompting review.
Aftercare
- Use the agreed non-drug approaches consistently across everyone involved in care.
- Keep watching for hidden causes — pain, infection, constipation, thirst or poor sleep.
- Give any medicine exactly as prescribed and report side effects such as drowsiness or stiffness.
- Keep all review appointments, especially to reassess whether a medicine is still needed.
- Keep a calm, familiar routine with daylight, gentle activity and good sleep habits.
- Look after yourself as a carer and accept support; your wellbeing affects the care you give.
- Seek urgent help for any sudden change, which may be delirium.
- A written care plan with the agreed approaches
- A note of known triggers and what helps
- A clear medicines list with review dates
- A named contact for advice between appointments
- Information on carer support services
- A plan for what to do if behaviour suddenly worsens
⚠ Get urgent help if…
- A sudden change in behaviour, alertness or confusion — this may be delirium and needs urgent assessment.
- Signs of pain or illness the person cannot explain, such as fever, not eating or drinking, or not passing urine.
- Severe agitation or aggression that puts the person or others at risk.
- Talk of wanting to die, or actions that put the person in danger.
- New stiffness, falls, drowsiness or difficulty swallowing after starting a medicine.
- A medicine being continued for months without anyone reviewing whether it is still needed.
- Carer exhaustion reaching the point of crisis — ask for help early.
Who to contact: your clinician, clinic or test provider first (keep their number to hand). For urgent advice when you can't reach them, call NHS 111. In an emergency, call 999.
General guidance — it doesn't replace the specific advice your psychiatrist gives you.
Results & realistic expectations
A good outcome is that the person is more comfortable, calmer and safer, with their dignity preserved, and that any treatable cause has been found and dealt with. For many, this is achieved largely through understanding and non-drug support.
No approach guarantees the symptoms will disappear, and they may change as the dementia progresses. Where medicine is used, success means the smallest effective dose for the shortest time, with regular checks that it is still needed and still safe — and stopping it when it is not.
BPSD tends to fluctuate and to change as dementia advances; some symptoms ease with time, others emerge. Plans therefore need regular review rather than being set once. Any medicine should be reviewed at intervals with an attempt to reduce or stop it, because the risks continue for as long as it is taken.
Related tests, treatments or support
Managing these symptoms goes hand in hand with treating physical health (pain, infection, constipation), reviewing all medicines, supporting sleep, and looking after carers. Where depression or anxiety is clearly present, that may be treated alongside, and a sudden change should prompt assessment for delirium.
Follow-up & long-term care
Follow-up is regular and active: reviewing what is helping, checking for new causes, and — crucially — reassessing any medicine to see whether it can be reduced or stopped. There should be a named contact for advice between reviews and a clear plan for urgent help if behaviour suddenly worsens.
- Keep a consistent, familiar routine with activity, daylight and good sleep.
- Treat pain, infection and constipation promptly before they trigger distress.
- Review medicines regularly, aiming to use the least medication necessary.
- Keep carers supported, trained and rested.
- Plan ahead for changing needs as the dementia progresses.
Repeat, follow-on and what comes next
- Plans need frequent adjustment as symptoms fluctuate and the dementia progresses.
- Any antipsychotic should be reviewed at regular intervals with an active attempt to reduce or stop it.
- What helps one person may not help another, so approaches are tailored and revised.
- A return of symptoms should prompt a fresh search for a cause, not automatic escalation of medicine.
Ask what happens if the result is unclear or needs repeating, and what is included if further tests or follow-up are needed.
What good aftercare looks like
- A written, person-centred care plan shared with everyone involved.
- Regular review of any medicine, with a clear intention to reduce or stop it.
- A named contact for advice and a plan for urgent help if behaviour suddenly worsens.
- Practical and emotional support for carers and care staff.
- Prompt reassessment for delirium or physical illness whenever there is a sudden change.
What affects the cost
Costs vary a great deal between people and providers, and we don't publish prices. What matters is understanding what drives the cost and making sure your quote is complete. The main things that affect it:
- Whether care is provided by a GP, memory service or specialist old age psychiatrist.
- How many appointments and reviews are needed over time.
- Whether home visits are involved.
- Any tests needed to look for causes such as infection.
- Carer training, support sessions or input from specialist nurses.
- Reports or care plans for families, care homes or other services.
- The clinician's fee and what each appointment includes.
- How follow-up and medication review are arranged and charged.
- Whether home visits are available and at what cost.
- Which tests are included and which are extra.
- Whether carer support and a written care plan are included.
- What happens, and what it costs, if symptoms suddenly worsen.
On the NHS? These symptoms are assessed and managed on the NHS through GP, memory and old age psychiatry services; private input may be used for speed, choice or a second opinion.
You're entitled to your total cost in writing — including reports, follow-up and what happens if the result is inconclusive — before you decide.
Consent traps and marketing red flags
These are not small details. They are often where patients lose choice, time to reflect, or realistic expectations.
Consent traps
- Starting a medicine without explaining the increased risk of stroke and death in dementia.
- No clear target for treatment and no planned review or stop date.
- Not exploring or treating physical causes before reaching for medication.
- Failing to involve the person, as far as they are able, and those close to them in decisions.
- Overlooking that the person may lack capacity, so best-interests decision-making under the Mental Capacity Act applies.
Marketing red flags
- Any service offering medication as a quick fix for agitation without assessment of causes.
- Promising to 'calm' or 'settle' a person without discussing risks or non-drug options.
- Routine, long-term sedation in care settings without regular review.
- Treating distress purely as a behaviour problem rather than as communication of a need.
Choosing a specialist safely
- Check the psychiatrist is on the GMC Specialist Register for this area.
- Make sure they work at a CQC-registered service, and look for membership of the relevant Royal College or professional body.
- You're entitled to time to consider and to have your questions answered before you agree — the psychiatrist who looks after you should explain it, not a salesperson.
- Be wary of pressure: time-limited offers or deposits taken before you've had time to think are red flags, not bargains.
- You're entitled to your total cost in writing — including any follow-up — before you decide.
Questions to ask your medical professional
Take this to your consultation. A good psychiatrist will welcome every one of these.
- Could there be a physical cause, like pain, infection or constipation, behind this behaviour?
- Could this sudden change be delirium, and does it need urgent assessment?
- What non-drug approaches should we try first, and how?
- If you suggest a medicine, what is the target, the risks, and when will it be reviewed and stopped?
- What type of dementia is this, and does it change which medicines are safe?
- What support is there for me as a carer?
- Are you on the GMC Specialist Register for this area, and which Royal College or professional body are you a member of?
- Will you be the psychiatrist who carries out my treatment, and who looks after me afterwards?
- What are the risks for someone like me, and how often do your own patients have a problem or need it repeated or redone?
- What does a realistic result look like — and what can this treatment not achieve?
- What are my options, including waiting, doing nothing for now, or choosing a different approach?
- Can I have written information, results and aftercare instructions in a format I can use, including any accessibility or communication support I need?
- What is the total cost in writing, including any follow-ups, and how much time do I have to decide?
Frequently asked questions
Why is my relative suddenly agitated or aggressive?
Should antipsychotic medicines be avoided in dementia?
What non-drug approaches actually help?
How long before we see improvement?
Is this treated on the NHS?
What about Lewy body dementia?
How do I check that a care home or care agency is properly regulated?
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How we made this page
Medically reviewed by a GMC-registered consultant. Written in plain English, checked against NHS, NICE, GMC and relevant Royal College / specialist-society guidance, and kept under review. No clinic paid to appear on this page, and we publish no pricing. This is general information to help you prepare — it is not a substitute for advice from your own clinician. How we review our guides →
Source hierarchy: UK regulator and NHS/NICE guidance first, then relevant Royal College or specialist-society guidance, then peer-reviewed evidence for procedure-specific figures where available.
Sources & standards: NICE NG97 — Dementia: assessment, management and support CQC — Appropriate use of psychotropic medicines in adult social care NHS — Dementia behaviour changes CQC — Care Quality Commission (England) Care Inspectorate (Scotland) Care Inspectorate Wales (CIW) RQIA — Regulation and Quality Improvement Authority (Northern Ireland)
Reviews reflect patients' experience of care, not clinical outcomes. For procedure volumes and outcome data see PHIN.
Last medically reviewed 2026-09-21. Spotted something wrong or out of date? Report an error in this guide.
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