Red flags
- Acute/subacute onset or fluctuation -> delirium until proven otherwise
- New focal neurology -> stroke, subdural
- Fever, tachycardia, hypoxia -> sepsis, PE
- Severe agitation with self/other harm risk
- Rapid progression over days-weeks (not typical BPSD tempo)
- Unrelieved pain behaviour (grimacing, guarding) - occult fracture, retention, impaction
Differential by mechanism
- Delirium (infection, drugs, metabolic, pain, constipation, urinary retention)
- Undertreated pain
- Substance withdrawal (EtOH, benzodiazepine)
- Structural - subdural, stroke, raised ICP
- Depression with agitation ("depressive pseudo-BPSD")
- Late-onset psychosis
- Anxiety
- Agitation/aggression, wandering, disinhibition, apathy, psychosis (hallucinations, misidentification)
- Sundowning
- Differs by dementia subtype - Lewy body: visual hallucinations + fluctuation early; FTD: disinhibition, apathy predominate over memory
Focused history
- Onset and tempo - acute (delirium) vs gradual (BPSD progression)
- ABC charting - Antecedent / Behaviour / Consequence, time of day pattern
- Collateral - carer/family/nursing home report, baseline cognition
- Pain, bowel/bladder function, sleep
- Medication changes - new anticholinergics, opioids, steroids, sedative withdrawal
- Psychiatric history, past response to agents
- Environmental triggers - room change, unfamiliar staff, overstimulation
Focused examination
- Vital signs, hydration, signs of infection
- Abdominal exam - constipation, retention (bladder scan)
- Skin - pressure areas, occult injury
- Neurological - focal signs, parkinsonism (caution: antipsychotic sensitivity in Lewy body)
- Cognitive screen if not already established (MMSE/MoCA), delirium screen (4AT/CAM)
- Pain assessment tools if non-verbal (Abbey Pain Scale, PAINAD)
Investigation strategy
- Delirium screen: FBE, UEC, CRP, glucose, calcium, TFTs, LFTs, MSU, CXR +/- septic screen
- Medication review - anticholinergic burden, recent additions
- CT brain if new focal signs, fall with head strike, anticoagulated, rapid progression
- Avoid reflexive neuroimaging in known stable dementia without new signs
Management
1. Treat reversible cause - infection, pain, constipation, retention, drug effect, hunger/thirst, environment
2. Non-pharmacological first-line - person-centred approach, consistent routine/staff, reduce overstimulation, redirect rather than confront, involve family, validate emotion not content of delusion
3. Pharmacological - only if severe distress or safety risk, non-pharm failed/inadequate
- Risperidone - only PBS-subsidised/TGA-approved antipsychotic for BPSD; short-term use only, lowest dose, regular review for cessation
- Black-box warning: inc stroke and mortality risk in dementia-related psychosis
- Avoid antipsychotics in Lewy body/Parkinson's dementia - severe neuroleptic sensitivity
- If unavoidable: quetiapine lowest dose
- Avoid benzodiazepines - worsen confusion, falls, paradoxical disinhibition; short-acting only for acute severe crisis
- Trial cessation regularly - antipsychotics for BPSD are time-limited, not maintenance
- Carer education, respite, Dementia Support Australia (Severe Behaviour Response Teams)
Traps
- Treating BPSD as a diagnosis rather than screening for delirium/pain first
- Antipsychotic use in Lewy body dementia -> severe sensitivity reaction
- Long-term antipsychotic continuation without cessation trial
- Physical restraint - increases agitation, injury risk, no evidence of safety benefit
- Assuming non-verbal distress is "just dementia" rather than pain or delirium
Talk track
Acute/fluctuating change in behaviour = delirium first - exclude infection, pain, constipation, retention, drugs. If genuine BPSD: non-pharmacological strategies first (routine, redirection, environment), pharmacotherapy only for severe risk/distress with regular cessation review - risperidone is the only approved agent, avoided in Lewy body dementia due to neuroleptic sensitivity.
Study aid only. These notes are written with the help of AI. Not for guiding clinical decisions.