Hostname: page-component-546b4f848f-zwmfq Total loading time: 0 Render date: 2023-06-04T10:08:22.655Z Has data issue: false Feature Flags: { "useRatesEcommerce": true } hasContentIssue false

Management of behavioral and psychological symptoms in people with Alzheimer's disease: an international Delphi consensus

Published online by Cambridge University Press:  02 August 2018

Helen C. Kales*
Program for Positive Aging, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA Department of Veterans Affairs, HSR&D Center for Clinical Management Research (CCMR), Ann Arbor, Michigan, USA Geriatric Research, Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
Constantine G. Lyketsos
Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview and Johns Hopkins University, Baltimore, Maryland, USA
Erin M. Miller
Program for Positive Aging, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
Clive Ballard
University of Exeter Medical School, Exeter, UK
Correspondence should be addressed to: Helen C. Kales, MD, Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Box 5765, Ann Arbor, Michigan 48109, USA. Phone: 7342320388; Fax: 7346158739. Email:



Behavioral and psychological symptoms of dementia (BPSD) are nearly universal in dementia, a condition occurring in more than 40 million people worldwide. BPSD present a considerable treatment challenge for prescribers and healthcare professionals. Our purpose was to prioritize existing and emerging treatments for BPSD in Alzheimer's disease (AD) overall, as well as specifically for agitation and psychosis.


International Delphi consensus process. Two rounds of feedback were conducted, followed by an in-person meeting to ratify the outcome of the electronic process.


2015 International Psychogeriatric Association meeting.


Expert panel comprised of 11 international members with clinical and research expertise in BPSD management.


Consensus outcomes showed a clear preference for an escalating approach to the management of BPSD in AD commencing with the identification of underlying causes. For BPSD overall and for agitation, caregiver training, environmental adaptations, person-centered care, and tailored activities were identified as first-line approaches prior to any pharmacologic approaches. If pharmacologic strategies were needed, citalopram and analgesia were prioritized ahead of antipsychotics. In contrast, for psychosis, pharmacologic options, and in particular, risperidone, were prioritized following the assessment of underlying causes. Two tailored non-drug approaches (DICE and music therapy) were agreed upon as the most promising non-pharmacologic treatment approaches for BPSD overall and agitation, with dextromethorphan/quinidine as a promising potential pharmacologic candidate for agitation. Regarding future treatments for psychosis, the greatest priority was placed on pimavanserin.


This international consensus panel provided clear suggestions for potential refinement of current treatment criteria and prioritization of emerging therapies.

Original Research Article
Copyright © International Psychogeriatric Association 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Alzheimer's Disease International (2010). World Alzheimer report: the global economic impact of dementia.; last accessed April 23, 2018.Google Scholar
Ballard, C. and Corbett, A. (2010). Management of neuropsychiatric symptoms in people with dementia. CNS Drugs, 24, 729739. doi:10.2165/11319240-000000000-00000.Google ScholarPubMed
Ballard, C. and Corbett, A. (2013). Agitation and aggression in people with Alzheimer's disease. Current Opinion in Psychiatry, 26, 252259. doi:10.1097/YCO.0b013e32835f414b.CrossRefGoogle ScholarPubMed
Ballard, C. et al. (2016). Impact of antipsychotic review and nonpharmacological intervention on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia living in nursing homes: a factorial cluster-randomized controlled trial by the well-being and health for people with dementia (WHELD) program. American Journal of Psychiatry, 173, 252262. doi:10.1176/appi.ajp.2015.15010130.CrossRefGoogle ScholarPubMed
Chenoweth, L. et al. (2009). Caring for aged dementia care resident study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurology, 8, 317325. doi:10.1016/s1474-4422(09)70045-6.CrossRefGoogle ScholarPubMed
Corbett, A., Nunez, K. and Thomas, A. (2013). Coping with dementia in care homes. Maturitas, 76, 34. doi:10.1016/j.maturitas.2013.06.002.CrossRefGoogle ScholarPubMed
Cummings, J. et al. (2014). Pimavanserin for patients with Parkinson's disease psychosis: a randomised, placebo-controlled phase 3 trial. Lancet, 383, 533540. doi:10.1016/s0140-6736(13)62106-6.CrossRefGoogle ScholarPubMed
Fossey, J. et al. (2006). Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. BMJ, 332, 756761.CrossRefGoogle ScholarPubMed
Fossey, J., Masson, S., Stafford, J., Lawrence, V., Corbett, A. and Ballard, C. (2014). The disconnect between evidence and practice: a systematic review of person-centred interventions and training manuals for care home staff working with people with dementia. International Journal of Geriatric Psychiatry, 29, 797807. doi:10.1002/gps.4072.CrossRefGoogle ScholarPubMed
Husebo, B. S., Ballard, C., Cohen-Mansfield, J., Seifert, R. and Aarsland, D. (2014). The response of agitated behavior to pain management in persons with dementia. American Journal of Geriatric Psychiatry, 22, 708–717. doi:10.1016/j.jagp.2012.12.006.CrossRefGoogle ScholarPubMed
Husebo, B. S., Ballard, C., Sandvik, R., Nilsen, O. B. and Aarsland, D. (2011). Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ, 343, d4065. doi:10.1136/bmj.d4065.CrossRefGoogle ScholarPubMed
Kales, H. C., Gitlin, L. N. and Lyketsos, C. G. (2014). Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society, 62, 762769.CrossRefGoogle ScholarPubMed
Kales, H. C., Gitlin, L. N. and Lyketsos, C. G. (2015). State of the art review: assessment and management of behavioral and psychological symptoms of dementia. BMJ, 350, h369.CrossRefGoogle ScholarPubMed
Maust, D. T. et al. (2015). Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm. JAMA psychiatry, 72, 438445. doi:10.1001/jamapsychiatry.2014.3018.CrossRefGoogle ScholarPubMed
Teri, L., McCurry, S. M., Logsdon, R. and Gibbons, L. E. (2005). Training community consultants to help family members improve dementia care: a randomized controlled trial. Gerontologist, 45, 802811.CrossRefGoogle ScholarPubMed
Testad, I. et al. (2014). The value of personalized psychosocial interventions to address behavioral and psychological symptoms in people with dementia living in care home settings: a systematic review. International Psychogeriatrics, 26, 10831098. doi:10.1017/s1041610214000131.CrossRefGoogle ScholarPubMed