**5. Behavioral disorders in dementia**

The psychological and behavioral symptoms of dementia (BPSD) are the most worrisome symptoms because they significantly affect the patient and his/her family or main caregivers. However, they are classically the symptoms that have received less attention. These are symptoms such as depression, anxiety, irritability, hallucinations, delirium, aggressiveness, etc. In fact, this symptomatology has a high degree of frequency and is present in at least 50– 90% of patients [104, 105]. Nevertheless, there is great variability in the percentages published, which shows the difficulty of estimating their prevalence.

BPSD have great repercussions because they cause a lot of problems for the patient and his/her family and social environment. They represent one of the consequences of the disease that produce the greatest disability, and one of the greatest threats to coexistence and the daily life of the family. They hinder the patient's autonomy and lead to frequent medical visits and admissions in emergency services and healthcare institutions. They have a decisive influence because they reduce the patient's quality of life and his/her level of functional autonomy [106], which leads to a decided reduction in the quality of life of the caregivers, increasing their stress. Thus, the caregivers of people with dementia suffer the consequences of these types of symptoms the most. Therefore, these symptoms become an important source of depression and desperation in caregivers [107], producing a large number of consultations with General Practitioners and becoming one of the main reasons for the institutionalization of AD patients [108, 109].

It is important to highlight that there is great heterogeneity in the appearance of these behavioral symptoms, given that not all patients present the same alterations, and they will not always appear in the same stages of the disease or increase linearly as the disease progresses [110].

Throughout the literature, diverse nomenclatures have been established to refer to this symptomatology. However, in 1996 the International Psychogeriatric Association coined the term psychological and behavioral symptoms of dementia (BPSD) to refer to the alterations in perceptions, mood, or behaviors that are often present in patients with dementia [111]. Specifically, they include a variety of manifestations, such as physical aggressiveness, shout‐ ing, restlessness, agitation, erratic wandering, hyperactivity, culturally inappropriate behav‐ iors, sexual disinhibition, abuse, inappropriate language, following another person around, etc. [112]. Below, **Table 2** shows the main alterations.

Numerous studies [85, 101–103] have shown the benefits of this therapy, observing that elderly people with AD who had participated in a reminiscence program, compared to a control group that did not participate, showed an improvement in the amount of autobiographical memory,

Therefore, reminiscence therapy is a useful intervention that has many benefits for both the healthy population and people with cognitive impairment. Specifically in the AD population, positive effects have been observed at the emotional, cognitive, and psychosocial levels.

However, and on the emotional plane, in addition to the changes mentioned, there is a broad range of emotional or psychological and behavioral impairment in AD that has to be treated

The psychological and behavioral symptoms of dementia (BPSD) are the most worrisome symptoms because they significantly affect the patient and his/her family or main caregivers. However, they are classically the symptoms that have received less attention. These are symptoms such as depression, anxiety, irritability, hallucinations, delirium, aggressiveness, etc. In fact, this symptomatology has a high degree of frequency and is present in at least 50– 90% of patients [104, 105]. Nevertheless, there is great variability in the percentages published,

BPSD have great repercussions because they cause a lot of problems for the patient and his/her family and social environment. They represent one of the consequences of the disease that produce the greatest disability, and one of the greatest threats to coexistence and the daily life of the family. They hinder the patient's autonomy and lead to frequent medical visits and admissions in emergency services and healthcare institutions. They have a decisive influence because they reduce the patient's quality of life and his/her level of functional autonomy [106], which leads to a decided reduction in the quality of life of the caregivers, increasing their stress. Thus, the caregivers of people with dementia suffer the consequences of these types of symptoms the most. Therefore, these symptoms become an important source of depression and desperation in caregivers [107], producing a large number of consultations with General Practitioners and becoming one of the main reasons for the institutionalization of AD patients

It is important to highlight that there is great heterogeneity in the appearance of these behavioral symptoms, given that not all patients present the same alterations, and they will not always appear in the same stages of the disease or increase linearly as the disease progresses

Throughout the literature, diverse nomenclatures have been established to refer to this symptomatology. However, in 1996 the International Psychogeriatric Association coined the term psychological and behavioral symptoms of dementia (BPSD) to refer to the alterations in

in order to improve the quality of life of the patient and his/her family context.

specifically semantic AM.

460 Update on Dementia

[108, 109].

[110].

**5. Behavioral disorders in dementia**

which shows the difficulty of estimating their prevalence.


**Table 2.** Main behavioral and psychological symptoms of dementia.

The evaluation and diagnosis of the BPSD is carried out through observation and interviews with the patient and his/her caregivers. In addition, instruments such as the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) [113] and the neuropsychiatric inventory (NPI) [114] can be quite useful.

#### **5.1. Main causes of behavioral disorders**

Behavioral problems have different origins. Below, a classification of these origins is presented:

#### *5.1.1. Medical causes that lead to behavioral problems*

First, many medications can produce secondary effects and cause confusion and changes in the level of functioning. In this situation, it is important to prepare a report of the changes occurring in the person.

Second, the sensory deficits that usually occur and accompany aging can lead to vision or hearing problems that can cause behavioral problems. Thus, it is important to carry out periodic revisions to avoid these problems.

Third, comorbidity with other diseases such as urinary infection, pneumonia, gastrointestinal infection, etc. can produce symptoms such as fever, which in turn will aggravate the confusion in the person with dementia, possibly leading to behavioral problems.

Fourth, situations of dehydration, constipation and other physiological causes such as hunger, sleepiness, or physical discomfort (e.g., headache, dizziness, etc.) can produce a strong feeling of distress and cause the person to behave in an irregular way.

#### *5.1.2. Causes related to the environment:*

At times, certain aspects or stimuli in the environment can produce some uncertainty, stress, or confusion in the patient. For example, very large and/or untidy spaces, too much stimula‐ tion, or a lot of activity in the environment (music while talking, too many people around, etc.) can make the person with dementia react with anger or frustration. In addition, an excess or lack of decorative elements, furniture, and lighting (e.g., visual contrasts between the wall and the floor, too much furniture, mirrors, etc.) and unfamiliar environments can interfere with orientation, creating more confusion.

Finally, people with dementia need a set routine and daily structure because environments without routines and disorganized surroundings can give rise to certain behavioral disorders.

#### *5.1.3. Causes related to the task:*

Certain characteristics of the task can cause some problem situations, for example:

A complicated task: Sometimes we ask a person with dementia to do tasks that are too difficult, even though they seem simple to us. Examples would be getting dressed or bathing.

An unfamiliar task: People with dementia gradually lose the ability to learn new tasks. If they are asked to do something they have never done before, they will not be able to learn it, no matter how simple it is. For example, if an appliance is changed, they will be incapable of learning how it works.

Too many tasks to do: The person is no longer able to do two or three things, especially at the same time. They do not know how to organize themselves or the order in which to do things, and they leave things half done and start something else, etc.

#### *5.1.4. Causes related to communication:*

**5.1. Main causes of behavioral disorders**

occurring in the person.

462 Update on Dementia

*5.1.1. Medical causes that lead to behavioral problems*

periodic revisions to avoid these problems.

*5.1.2. Causes related to the environment:*

orientation, creating more confusion.

*5.1.3. Causes related to the task:*

learning how it works.

Behavioral problems have different origins. Below, a classification of these origins is presented:

First, many medications can produce secondary effects and cause confusion and changes in the level of functioning. In this situation, it is important to prepare a report of the changes

Second, the sensory deficits that usually occur and accompany aging can lead to vision or hearing problems that can cause behavioral problems. Thus, it is important to carry out

Third, comorbidity with other diseases such as urinary infection, pneumonia, gastrointestinal infection, etc. can produce symptoms such as fever, which in turn will aggravate the confusion

Fourth, situations of dehydration, constipation and other physiological causes such as hunger, sleepiness, or physical discomfort (e.g., headache, dizziness, etc.) can produce a strong feeling

At times, certain aspects or stimuli in the environment can produce some uncertainty, stress, or confusion in the patient. For example, very large and/or untidy spaces, too much stimula‐ tion, or a lot of activity in the environment (music while talking, too many people around, etc.) can make the person with dementia react with anger or frustration. In addition, an excess or lack of decorative elements, furniture, and lighting (e.g., visual contrasts between the wall and the floor, too much furniture, mirrors, etc.) and unfamiliar environments can interfere with

Finally, people with dementia need a set routine and daily structure because environments without routines and disorganized surroundings can give rise to certain behavioral disorders.

A complicated task: Sometimes we ask a person with dementia to do tasks that are too difficult,

An unfamiliar task: People with dementia gradually lose the ability to learn new tasks. If they are asked to do something they have never done before, they will not be able to learn it, no matter how simple it is. For example, if an appliance is changed, they will be incapable of

Certain characteristics of the task can cause some problem situations, for example:

even though they seem simple to us. Examples would be getting dressed or bathing.

in the person with dementia, possibly leading to behavioral problems.

of distress and cause the person to behave in an irregular way.

Another possible cause of these problems stems from the existence of comprehension and/or expression difficulties. Communication between the family and the person with dementia is extremely important and can be difficult. People with dementia often become angry or agitated because they do not understand what is expected of them, or they get frustrated because they cannot make themselves understood. These difficulties in communication and adaptation to their surroundings arise because there are hidden or unsatisfied needs, due to behavioral learning (reinforcement systems), greater vulnerability to the environment, or less adaptation to stressful situations.

When there are hidden or unsatisfied needs that have not been identified, they can cause inappropriate behavior. These needs are often not detected by caregivers, or they do not know how to respond to them (e.g., sensory deprivation, boredom, etc.). In a recent study, the number of unaddressed needs was the main factor associated with BPSD [115]. Among these needs, there are three main types: biological (lack of food, sleep, lighting, temperature, etc.); psychological (security, empathy, affect, etc.); and social (social company, boredom, respect, etc.). The most frequently detected needs were related to doing activities, company, and help with psychological distress [115].

Regarding behavioral learning, the environmental stimuli maintain, extinguish, or change a behavior, depending on the associated reinforcement. Thus, in the presence of an antecedent stimulus, a behavior is produced, which has a consequence. But if there is a change in the antecedent or the consequence, there is a direct change in the behavior. When referring to the consequences of a behavior, we can talk about different behavioral reinforcement systems. Depending on the reinforcement applied, we can cause a behavior to increase, remain the same, or disappear. However, often the behavior of the caregiver can be creating or maintaining the BPSD, given that they positively reinforce behaviors that should be eliminated, thus producing an increase in these behaviors. For example, a caregiver could be reinforcing an agitated behavior if he/she only pays attention to the person with dementia when he/she is restless or agitated. Other caregiver behaviors that can create or maintain BPSD are: paternalistic authoritarian or infantilizing treatment, ignoring the patient, imposing things or power struggles, or frequently asking the same thing so that the patient will remember it [116]. Therefore, we must eliminate the positive reinforcement of inappropriate behaviors and promote the positive reinforcement of appropriate ones. We can also establish the learning of new behaviors by generating new stimulus-response associations; for example, if we want the patient to learn a new behavior, we have to encourage it as a response to a stimulus and reinforce it positively every time it appears.

Finally, another reason for this type of disorder is the vulnerability to the environment or poor adaptation to stressful situations. This vulnerability arises because patients gradually lose their ability to adapt to their surroundings or cope with a situation of stress, perceiving the envi‐ ronment as stressful and threatening. When the environmental stimuli surpass their stress tolerance threshold, they can cause anxiety, and this can lead to inappropriate behaviors. Examples of some stressful factors would be loud or irritating noises, shouts, excess heat/cold, unknown places that can be perceived as threatening, etc. Thus, in this situation, we must try to adapt the environment to the person's needs.

#### **5.2. Intervention in behavioral disorders**

Nonpharmacological therapies, specifically behavioral interventions, are usually the treat‐ ment of choice for BPSD, and although there are few results in the literature supporting its efficacy, a set of actions have been identified that integrate psychosocial and medical perspec‐ tives and respond to a coordinated and established plan. However, when these types of disorders are more serious, behavioral intervention is combined with pharmacological treatment. In practice, professionals should at least know about the essential components of the care management plan, promoting interactions between the parties involved in an agile and comfortable way for the person with dementia and the caregiver.

The essential aspects of the care management plan are early diagnosis, specific pharmacolog‐ ical treatment, control over comorbidity, prevention and treatment of the BPSD, and the continuous guidance and support for the patient and caregiver [117].

Before making changes, it is necessary to make a general proposal to find out what we want to change. Therefore, first the behavior to be modified must be defined. The definition of the behavior must be carried out in a specific and concrete way. Thus, this proposal includes:


However, in order for a behavioral intervention to be successful, it is important to take into account the environment and the family setting, so that they remain constant and do not produce stress. In addition, this environment must continually be adapted to the patient's different needs and the evolution of the disease. However, it is also reasonable to imagine that other nonpharmacological therapies that have a special influence on the affective sphere (reminiscence, music therapy, leisure activities, etc.) also avoid the appearance of BPSD [81, 103, 118].

Nevertheless, and in spite of the consensus between professionals and scientific societies about the priority of nonpharmacological management, certain circumstances, such as the lack of human resources for the necessary care, make it necessary to use pharmacological treatment for the BPSD. In this case, treatment with cholinesterase inhibitors reduces the appearance of apathy, hallucinations, and motor hyperactivity [119, 120], while memantine prevents the appearance of agitation and aggressiveness [121].

Specifically, for intervention in the main BPSD:

ronment as stressful and threatening. When the environmental stimuli surpass their stress tolerance threshold, they can cause anxiety, and this can lead to inappropriate behaviors. Examples of some stressful factors would be loud or irritating noises, shouts, excess heat/cold, unknown places that can be perceived as threatening, etc. Thus, in this situation, we must try

Nonpharmacological therapies, specifically behavioral interventions, are usually the treat‐ ment of choice for BPSD, and although there are few results in the literature supporting its efficacy, a set of actions have been identified that integrate psychosocial and medical perspec‐ tives and respond to a coordinated and established plan. However, when these types of disorders are more serious, behavioral intervention is combined with pharmacological treatment. In practice, professionals should at least know about the essential components of the care management plan, promoting interactions between the parties involved in an agile

The essential aspects of the care management plan are early diagnosis, specific pharmacolog‐ ical treatment, control over comorbidity, prevention and treatment of the BPSD, and the

Before making changes, it is necessary to make a general proposal to find out what we want to change. Therefore, first the behavior to be modified must be defined. The definition of the behavior must be carried out in a specific and concrete way. Thus, this proposal includes:

**1.** Identify the BPSD that should be modified and make the clearest and most concise definition possible in order to better delineate the problem. In this way, the best action strategy for this specific BPSD (it is better to address them one by one) can be identified.

**2.** In order to adequately define the BPSD, information has to be gathered about it: what time of day it appears, in what environment or context, who is present, how often it appears,

**3.** Locate the antecedents or triggers and consequences of the behavior. There can be various triggers, and the more the interrelations among these factors are determined, the more successful the intervention will be. Regarding the consequences of the behavior, they allow us to establish the intensity of the problematic symptom or behavior, and in

**4.** Realistic goals have to be set, beginning with small ones that are easy to achieve. A realistic goal does not involve making all the behavior problems disappear completely and forever. Goals have to be established in relative terms. The objective might be for the behavior to appear less frequently, be less intense, last less time, produce less discomfort in the patient, and/or be better tolerated by the caregiver. The changes are slow, and it takes time to begin

analyzing the consequences, the key to the triggers can often be found.

and comfortable way for the person with dementia and the caregiver.

continuous guidance and support for the patient and caregiver [117].

to adapt the environment to the person's needs.

**5.2. Intervention in behavioral disorders**

464 Update on Dementia

etc.

to see them.

Thought alterations, hallucinations and delirium: Avoid triggers, arguing about the truth or joking; do not reinforce or increase the content of the altered thinking; orient and distract the person toward other topics.

Aggressiveness: Review the existence of a possible depravation or a need that may be pro‐ voking it; promote autonomy and privacy (avoid robbing the patient of his/her dignity); approach the patient face-to-face calmly, warn, use nonverbal communication, explain, negotiate, reinforce, etc.

Depression: Identity the possible trigger and modify it (mourning, entering a nursing home, etc.); provide light, open, and pleasant spaces; stimulate social interaction; establish a plan for pleasant and enjoyable activities (strolls, workshops, etc.).

Anxiety: Reduce stimuli; continuous explanation of what is going to happen and predicting new situations; offer security verbally and nonverbally; avoid distractors, etc.

Euphoria: Do not imitate or reinforce the patient; do not trivialize, try to put him/her in the place of others. Correct or offer affection in a respectful way.

Apathy: Verbal or physical requests, propose, and persuade the patient to do pleasant or group activities, imitation, and modeling, stimuli with movement and an affective component (music, animals, etc.). The caregiver must understand and know how to manage this symptom.

Disinhibition: Study possible triggers (getting undressed because they are hot or because a label irritates their neck), respect without judging, avoid getting irritated or angry about behaviors, understand the behavior as part of the disease, correct them with tact, etc. In the case of inappropriate sexual behaviors, try to carry out stimulus control, allowing the behavior in certain places and for a certain time and impeding it in other situations (differential and selective reinforcements).

Irritability: Study a possible modification of the environment (noise, caregiver's treatment, social setting, etc.), accept the limitations, propose realistic, and alternative activities, etc.

Motor-ambulation hyperactivity: Make sure shoes are suitable, appropriate spaces, and establishing safety measures such as constant supervision, railings, good lighting, direction signals, signs, eliminate obstacles, black rugs, etc., offer objects to manipulate, do not create obstacles, etc.

Repeated vocalizations: Check basic needs with special attention to social isolation, lack or excess of stimuli, or pain; reinforce calm moments.

Sleep alterations: Balanced diet, brief naps, activity during the day, delay bedtime, avoid noise, etc.

Increase in appetite: Reduce or avoid exposure to food or substances.

Loss of appetite: Reinforce with aromas, flavors and presentation of food, dental hygiene and check-ups, conversation during meals, select favorite meals, etc.
