Practical guidance for primary care clinicians on identifying, evaluating, and managing behavioral symptoms of dementia while minimizing medication use.

Published: February 3, 2026

Nearly all individualswith dementia will experience behavioral or psychological symptoms during their disease course, presenting significant challenges for caregivers and clinicians alike. Understanding how to identify, evaluate and manage these symptoms while minimizing medication use remains essential for improving patient outcomes and quality of life. In a recent “MedChat” podcast, Rachel N. Hart, D.O., geriatric medicine and memory specialist with Norton Neuroscience Institute Memory Center, discusses this topic with Gregory E. Cooper, M.D., Ph.D., Norton Neuroscience Institute chief of adult neurology and director of the Memory Center.

Understanding the scope

“Approximately 97% of individuals with dementia develop some form of behavioral or psychological symptom throughout the disease progression,” said Dr. Hart. “These symptoms vary considerably based on disease stage and dementia type, requiring clinicians to adopt individualized approaches.”

The most prevalent symptoms include apathy, anosognosia and anxiety.

• Apathy— frequently mistaken for depression or boredom, stems from severe memory impairment that diminishes an individual’s’ ability to initiate tasks.
• Anosognosia — the inability to recognize one’s own cognitive impairment — often appears as denial to family members but represents a genuine neurological symptom.
• Anxiety —  manifests differently across disease stages, from social withdrawal and tearfulness in early dementia to restlessness and shadowing behaviors in advanced stages.

Distinguishing key clinical presentations

Clinicians must differentiate behavioral and psychological symptoms of dementia from delirium and primary psychiatric conditions. Behavioral and psychological symptoms in dementia (BPSD) typically develop gradually alongside documented cognitive decline and functional impairment. In contrast, delirium presents acutely or subacutely over days to weeks, usually associated with medical illness, infection or hospitalization, and generally resolves with treatment of the underlying cause.

Primary psychiatric conditions like schizophrenia or bipolar disorder present earlier in life and persist independent of cognitive impairment. A thorough medical history remains the cornerstone of accurate diagnosis.

Stage-specific symptom patterns

Behavioral symptoms evolve as dementia progresses.

Early-stage individuals with dementia often retain awareness of cognitive decline, leading to depression, anxiety, social withdrawal and irritability as they struggle with loss of control. These individuals may benefit from acknowledgment of their difficulties and supportive interventions.

Moderate-stage dementia brings decreased awareness of deficits alongside emergence of psychiatric symptoms, including delusions, hallucinations, paranoia and suspiciousness. Individuals with dementia may accuse caregivers of theft or harbor unfounded beliefs about threats. Sleep disruptions frequently develop during this phase.

Severe-stage individuals with dementia require 24-hour care and lose the ability to communicate needs effectively. Behavioral symptoms often reflect unmet physical needs — pain, hunger, thirst, constipation or urinary retention. Restlessness and apathy predominate, driven by communication barriers rather than primary psychiatric pathology.

Evaluating and characterizing behaviors

Effective management begins with precise characterization. Caregivers may report heightened agitation, but that requires clarification.

“Is the patient frustrated? Or are they physically aggressive? It is critical to parse those behaviors clearly,” Dr. Hart said. “Clinicians should document specific behaviors, frequency, temporal patterns and potential triggers.”

Key assessment questions include: When did the behavior start? How often does it occur? Does it happen during specific activities like bathing or bedtime? Can the patient be redirected? Does the behavior pose safety risks?

This detailed characterization guides treatment selection and provides metrics for evaluating intervention effectiveness.

Identifying underlying triggers

Many behavioral symptoms represent attempts to communicate unmet needs, particularly in moderate to severe dementia. Physical stressors — constipation, urinary retention, infection, hunger, thirst — commonly trigger behavioral changes in individuals with dementia unable to articulate discomfort.

Psychological needs matter equally. Loneliness, boredom, fear of caregiver separation and lack of meaningful activity all contribute to behavioral symptoms. Environmental factors like overstimulation, unfamiliar settings or demanding tasks can provoke distress.

Nonpharmacologic interventions: First-line approach

Medication should be reserved for situations where nonpharmacologic strategies fail or safety concerns demand immediate intervention. Evidence supports several behavioral approaches as first-line management.

Establishing structured daily routines helps individuals with dementia maintain sleep-wake cycles and provides predictability. Regular wake times, meals, exercise and bedtimes reduce anxiety and confusion. Physical activity, even simple walking, improves mood and sleep quality.

Communication strategies prove essential. Caregivers should simplify questions and instructions, offer limited choices rather than open-ended options, avoid correcting someone with dementia repeatedly and practice patience. For example, instead of presenting an entire menu, offer two specific choices the patient historically preferred.

The concept of therapeutic fibbing or compassionate deception deserves consideration. When individuals with dementia repeatedly asks about deceased loved ones or past events, providing comforting responses that avoid triggering grief can be humane. A patient asking for a deceased spouse might be told the person is running errands rather than being forced to relive the loss repeatedly.

Modifying triggering activities improves outcomes. If bathing causes distress, consider sponge baths, breaking the task into smaller steps or playing preferred music during the activity. Dignity and respect remain paramount — individuals with dementia are still people with preferences and feelings.

Pharmacologic management: When necessary

When medications become necessary, treatment should target specific symptoms, using the lowest effective dose for the shortest duration possible.

For depression and anxiety symptoms — tearfulness, worry, social withdrawal — selective serotonin reuptake inhibitors like sertraline or citalopram represent first-line options. These agents generally provide good tolerability in older adults.

Psychotic symptoms, including hallucinations and delusions, may require antipsychotic medications when they pose safety risks or prevent essential care. Second-generation antipsychotics like quetiapine or risperidone have fewer side effects than older agents, though all antipsychotics carry risks in individuals with dementia. Clinicians should carefully weigh benefits against potential adverse effects, including increased mortality risk.

Physical aggression may respond to antipsychotics or mood stabilizers like valproate, depending on symptom characteristics and patient factors.

Sleep disturbances deserve special attention given their impact on both individuals with dementia and caregivers. Nonpharmacologic approaches include limiting caffeine, reducing fluids before bedtime and establishing consistent sleep routines. Over-the-counter options like magnesium glycinate or melatonin offer safe initial trials. When prescription medications prove necessary, trazodone or mirtazapine provide better safety profiles than medications like zolpidem in older adults.

Regular reassessment allows discontinuation of medications when symptoms improve, as behavioral symptoms often wax and wane throughout dementia progression.

Leveraging interdisciplinary resources

Busy clinicians can extend their impact through interdisciplinary collaboration. Occupational therapists help individuals with dementia maintain independence and establish adaptive routines. Social workers connect families with community resources, including adult day programs, respite care and disease-specific organizations like the Alzheimer’s Association. Nurse navigators coordinate care and provide education.

Primary care physicians lacking access to specialty dementia clinics still can refer individuals with dementia to these individual services to augment direct care.

Clinical pearls

Three principles should guide clinical management of BPSD:

• Precisely describe behaviors, including specific manifestations, frequency and triggers. This characterization directs appropriate interventions and provides objective measures for assessing treatment response.
• Recognize that BPSD evolves with disease progression. Medications initiated for specific symptoms may not require indefinite continuation. Regular reassessment allows deprescribing when appropriate.
• Prioritize nonpharmacologic interventions. Environmental modifications, communication strategies and trigger avoidance often prove most effective throughout the disease course.

The foundation of successful BPSD management rests on caregiver education and support. Teaching families to communicate effectively, modify environments and maintain patient dignity extends far beyond any pharmaceutical intervention. As the population ages and dementia prevalence rises, equipping clinicians with practical tools for managing behavioral symptoms becomes increasingly vital for improving patient and caregiver quality of life.