Behavioral and psychological symptoms of dementia (BPSD) are defined as the signs and symptoms suggestive of disturbances in perception, thought content, mood and behavior.

These behavioral and psychological symptoms have been divided into two groups:

• symptoms assessed usually and primarily by patient and family interviews. These symptoms are: anxiety, depressed mood, hallucinations and delusions and
• symptoms usually detected by observation of the patient’s behavior: aggression, shouting, restlessness, restlessness, wandering, culturally inappropriate behavior, sexual disinhibition, hoarding, cursing.

In addition to suffering, behavioral disorders aggravate the loss of functional autonomy, disturb those around them and are often the cause of hospitalization and permanent institutionalization.

They increase health care costs and greatly affect the quality of life of the patient, their family and other health care providers.

In institutions, the appearance of these disorders represents a real challenge for the medical team who must diagnose them in time in order to better treat them with a dual therapeutic and behavioral approach.

Finding the cause is important because it allows you to choose the most appropriate treatment (antidepressant, antipsychotic). The doctor will look for the existence of triggering factors.

Type and frequency of behavioral and psychological symptoms

These symptoms can be categorized according to the type of symptoms:

The behavioral and psychological symptoms of dementia can be classified according to their frequency and difficulties in management:

About 60-90% of patients with dementia related to Alzheimer’s disease show behavioral problems during the course of the disease. According to the REAL study, the frequency of behavioral and psychological symptoms is very high ranging from 84% for people with an MMSE test score of 21 to 30 to 92.5% of patients when the MMSE test score is between 11 and 20 .

Behavioral and psychological symptoms occur at different stages of the disease. Affective symptoms are more likely to appear at an early stage of the disease. Agitated and psychotic behaviors are common in patients with moderate cognitive impairment; however, they become less apparent in advanced stages of dementia, most likely due to deterioration in the patient’s physical condition.

It is often the nurses and caregivers who generally notice them first. The earliest are signs of depression, anxiety, apathy, disinterest, social withdrawal. Then follow the noisiest: agitation, aggressiveness, disinhibition.

Symptoms depend on the type of dementia

Psychological behavioral symptoms are not the same in all dementias: emotional disturbances and apathy often dominate in Alzheimer’s disease, while hallucinations are present in 80% of people with Lewy body dementia; agitation, aggressiveness, apathy dominate in vascular dementias, and impulsive behaviors, agitation, disinhibition characterize frontotemporal dementias.

Some psychological behavioral symptoms are more persistent than others. For example, over a 2-year observation period, one study demonstrated that wandering and restlessness are the longest-lasting behavioral symptoms in patients with Alzheimer’s disease.

Similar profiles have been found in patients with Alzheimer’s disease and vascular dementia. All symptom levels were high (30% of all patients had three or more psychiatric symptoms) and increased with the severity of dementia. Agitation was the most frequent symptom, followed by symptoms of depression, apathy and aberrant behavior.

Other studies have also reported that there was no difference in behavioral profile between patients with Alzheimer’s disease and those with vascular dementia.

Visual hallucinations are more commonly seen in patients with dementia with Lewy bodies than in those with Alzheimer’s or Parkinson’s disease.

These hallucinations occur in nearly 80% of patients with dementia with Lewy bodies, compared to nearly 20% in those with Alzheimer’s disease.

Frequency and evolution of psychological behavioral symptoms in Alzheimer’s disease

Psychological behavioral symptoms in frontotemporal and Lewy body dementia

Depression and apathy

Depression represents a differential diagnosis of dementia but it can also be part of the clinical picture of Alzheimer’s disease (early stage) .

Depressive symptoms affect a sizable minority of patients with dementia at some stage of development. Most studies, conducted with patients with Alzheimer’s disease, have shown that depressed mood is found more frequently (40-50% of patients), while depressive disorders are less common (10-20%) . A 5-year longitudinal study of patients with Alzheimer’s disease found relapse rates of 85% for depressive symptoms over a one-year period.

The diagnosis of depression can be difficult to establish, particularly in patients with moderate or severe dementia. In the early stage of dementia, depressed mood and its symptoms can usually be determined during the medical consultation.

As dementia progresses, it becomes more difficult to establish the diagnosis of depression due to the increasing presence of speech and communication difficulties, apathy, weight loss, sleepiness and restlessness that accompany dementia.

A depressive disorder should therefore be considered if:

• pervasive depressed mood and anhedonia (inability to feel positive emotions caused by a feeling of disinterest);
• self-devaluation and desire to die;
• personal or family history of depression prior to the onset of dementia.

The prescription of an antidepressant -without anticholinergic properties- is justified.

Apathy and its associated symptoms affect up to 50% of patients in the early and middle stages of Alzheimer’s disease and other forms of dementia. Patients with apathy present with:

• lack of interest in activities of daily living and self-care;
• decreased social interaction;
• a decrease in facial expressiveness;
• a more monotonous voice;
• decreased emotional reactivity;
• loss of initiative.

Symptoms of apathy can be confused with those of major depression. Both states can manifest as a decline in general interest, psychomotor retardation, lack of energy and insight.

Although a lack of motivation also accompanies the states of apathy and depression, the apathy syndrome denotes a lack of motivation without the vegetative symptoms of depression being present.

The drug treatment of apathy is different from that of depression (the doctor will prescribe an antidepressant to a depressed patient, and a psychostimulant in case of apathy).

Anxiety

Anxiety is with depression the affective disturbance most frequently found (50% of cases) in demented patients. It can precede cognitive disorders to the point that its recent appearance in an individual should lead to the evaluation of his cognitive functions. Demented patients with anxiety will express previously unmanifest concerns and fears about their finances, future, and health (including memory), and fears about events and activities, like being away from home.

The patient may incessantly repeat questions relating to an upcoming event (this is Godot’s syndrome). Another symptom of anxiety characteristic of the demented patient is the fear of being left alone. This form of phobia can manifest itself as soon as the carer goes to another room in the home (the patient follows the carer in his movements) and can be expressed by the patient’s repeated requests not to be left alone. Other phobias may also appear, such as a fear of travelling, being left in the dark, or taking a bath.

It is often difficult to spot anxiety in a person with dementia. Indeed, aphasia can prevent the verbal communication of affects and transform the expression of emotional disorders. Similarly, emotional responses may be maladaptive due to misinterpretation of a stimulus.

Apraxia can also impair nonverbal emotional expression abilities.

Sometimes, the demented subject adopts defense mechanisms against anxiety: for example, he will invoke a relative as if he were still alive. When the dementia is more pronounced, the anxiety presents itself in a more physical form: aggressiveness, running away, incessant wanderings…

Agitation and aggression

They are relatively infrequent but can create a climate of disorganization in an institution. Agitation is defined as inappropriate verbal, vocal or motor activity that is not the result of an immediate need or a state of confusion. Interventions must be immediate and based on the intensity of the crisis.

Aggression is a feared behavioral disorder because it is difficult to control. A distinction must be made between verbal aggression (anger, insults, shouting, etc.) and physical aggression (violent gestures). This type of behavior generally takes shape during exchanges between the patient and the carer (toilet, dressing, meals, bedtime).

There are four forms of agitation/aggressiveness:

Non-aggressive physical behavior :

• repetitive gestures (eg hoarding objects – pencils, cups, toiletries, clothes – that are in the room of other patients;
• comings and goings;
• wandering around, entering other patients’ rooms or bathrooms, lying in their beds;
• attempts to travel to another location;
• hiding objects, tearing things up, throwing them in the toilet;
• inappropriate urination or defecation, including handling stool;
• wearing inappropriate clothing;
• knocking over food trays, eating from other patients’ trays;
• take objects belonging to other patients and staff members (glasses, teeth, pants).

Non-aggressive verbal behavior :

• negative attitude;
• to love nothing;
• constant attention seeking;
• give orders;
• whining complaints or grievances;
• relevant interruptions;
• repetition of sentences.

Aggressive physical behavior :

• to kick;
• jostle;
• scratch;
• seize objects;
• grabbing people;
• kicking and biting;
• pull out restraints or catheters.

Aggressive verbal behavior :

• to yell;
• display inappropriate hostility (insults; calls, swearing, shouting* etc.);
• surge of anger;
• make strange sounds.

* Cries most often occur when the person is alone in their room, in the evening or at night. Their appearance is more important at the time of interventions carried out in a situation of constraint for the person (toilet, dressing). It is necessary to determine whether these cries come from pain or are the cause of a manifestation of fear, a depressive state or moral suffering that cannot be expressed in words. The installation of bed rails generally increases the intensity and duration of these cries in some patients. It is therefore important to stimulate the patient as much as possible by providing him with activities adapted to his condition (playing of musical tapes, video-cassettes evoking family memories).

Dementia by itself does not completely explain the agitation phenomenon. Indeed, other factors – medical, psychological and environmental – are involved in agitation.

It is important to have a calm attitude and voice, to try to appease the patient by word and gesture, not to be more than three people involved (the patient may feel threatened). It is sometimes necessary to isolate the patient in his room, knowing that there is a risk of a panic attack. Restraints are to be avoided, as they often increase the intensity of the crisis.

The causes and triggering factors depend on the personality of the patient and his situation: it may be, for example, a reaction to pain, an annoyance (loss of a life habit), a reaction to an over -stimulation (sensory or cognitive) for the patient who no longer has the ability to respond.

For example, a patient may be aggressive or even violent if the nursing staff refuses her access to her bathroom after her meal. An interview with one of her children will make it possible to understand the reasons for her anger: she had the habit of brushing her teeth after each meal, a habit which had not been followed when she entered an institution (this is an annoyance relating to that of care which must take place in an institution at specific times).

Delusional Disorders

The frequency of delusions in people with dementia is between 10% and 73% depending on the population studied. About a third of patients with probable Alzheimer’s disease suffer from delusions, and are considered to be at risk for physical aggression. According to one study, 80% of participants with high levels of physical aggression (>1 episode/month) also suffered from delusions. Patients with Lewy body dementia very often present with delusional pathology (about 80%).

Delusional disorders at the beginning of the dementia stage revolve mainly around forgetfulness. They lead to ideas of displacement and theft of objects, intrusion into the home…

They may be accompanied by aggressiveness in a person with a psychiatric history. As the disease worsens, the delusions aim to fill the growing void caused by the memory loss, and draw on the remnants of memories still intact in the patient. The most frequent delusional themes are theft, prejudice and infidelity and jealousy (15% of cases).

The Behavioral Pathologic Rating Scale for Alzheimer’s disease is a behavioral disorder rating scale that describes the different forms of delirium in Alzheimer’s disease. These forms are classified by theme (theft, impostor syndrome, etc.):

The patient believes that he has had things stolen (frequency = 18% to 43%)

Likely explanation: the patient does not remember the location of their personal items. He will therefore be led to blame a third party for their disappearance. In serious forms, he is convinced that people break into his home with the aim of hiding or stealing objects.

The patient believes he is living in a home that is not his

The patient does not remember or recognize his home. He may end up leaving it to return « home » (this is the phenomenon of wandering).

The spouse (or the relative in charge of the patient) is perceived as an impostor

The patient no longer recognizes his loved one. He can also consider the family caregiver or his doctor as an impostor, leading to a reaction of mistrust, even of great violence. This may be similar to an identification disorder (this is Capgras syndrome).

A feeling of abandonment (frequency = 3% to 18%)

The patient is convinced that he has been abandoned, that he will be placed in an institute, and that a plot is being organized for this purpose. This feeling stems from the fact that he realizes the burden he represents for those around him because he retains a certain awareness of his condition. Relatives feel guilty for this feeling of abandonment experienced by the patient.

A feeling of infidelity (frequency = 1% to 9%)

This feeling mainly concerns the spouse or caregivers.

Although the diagnosis of delirium is sometimes difficult in a person with dementia (indeed people with dementia already have a disorder of ideation and confusion), it is possible, with some experience, to tell the difference between delirium and dementia.

Indeed, delirium is usually accompanied by:

• a sudden onset of symptoms;
• a decrease or increase in alertness in the patient already presenting with dementia, or a marked fluctuation in symptoms;
• visual hallucinations accompanied by agitation;
• impaired psychomotor activity;
• language disorders (slurred speech, slowing or speeding up of speech);
• of tremors.

Once the diagnosis of delirium is made, the choice of treatment will depend on identifying the cause. These causes are many and include:

• medication side effects;
• malnutrition;
• an infection;
• cerebral pathologies (e.g. subdural hematomas);
• endocrine disorders (eg hyperthyroidism);
• metabolic diseases (eg certain kidney or liver conditions);
• patient environmental factors;
• Hypoxia caused by pneumonia, congestive heart failure or sleep apnea;
• Urinary retention or fecal impaction (accumulation of feces).

Hallucinations

Hallucinations interfere with the patient’s ability to understand the outside world. This phenomenon can alter their ability to perform activities of daily living and can affect their relationship with caregivers. The frequency of hallucinations in people with dementia ranges from 12 to 49%.

Visual hallucinations are the most common (up to 30% of patients with dementia), and they are more common in moderate dementia than in mild or severe dementia. Auditory hallucinations are present in 10% of dementia cases. Other forms of hallucinations – tactile and olfactory – are rare.

A common type of visual hallucination involves observing the presence of certain people in one’s home, when in fact they are not there. In the case of Lewy’s dementia, the interpretation disorders are based above all on gnosic deficits, and to a lesser extent on mnesic disorders and sensory perception defects.

The most frequently observed gnosic deficits are prosopagnosia (the patient does not recognize his relatives; 12% of cases), self-agnosia (4% of cases), intrusion of people into the patient’s life ( 6% of cases), or the ghost companion syndrome (the patient is convinced that a person is hiding in his home (17% of cases). These hallucinations sometimes require treatment when they are a source of stress. This treatment depends on the etiology.

There seems to be a relationship between a decrease in visual acuity and hallucinations (Bonnet syndrome is quite common). Indeed, a significant percentage of people with dementia have visual impairment (e.g. visual agnosia characterized by difficulty recognizing faces or objects), and many experience difficulty in contrast perception, especially at low frequencies. In these patients, the line of demarcation between the areas of shadow and light appears blurred, which partly explains the high rate of identification disorders and visual hallucinations. It is therefore important to assess the visual perception functions of patients with dementia and suffering from hallucinations. From a practical point of view,

An attitude of empathy from the nursing staff is often the most effective approach when dealing with a patient suffering from delusion of flight. The nurse can then look with him for the objects supposed to have disappeared, which has the effect of reassuring him.

Wandering

Wandering (also called motor hyperactivity) describes a set of manifestations during which the patient follows and seeks caregivers throughout the day. This wandering can be aimless or will be characterized on the contrary by comings and goings between two very specific places. These manifestations, specific to demented states but whose causes are complex, would be the expression of boredom, sadness or anxiety. Here are some causes that would be at the origin of this type of behavior: hyperactivity, orientation disorders leading to seek new landmarks, attempt to escape or escape isolation,

These problems are the most delicate to manage at home, which obliges the relative to hospitalize the patient.

It should be noted that the ambulation associated with akathisia can be caused by the side effects of antipsychotics, effects which persist for several months after stopping treatment.

The management of ambulation primarily involves non-drug treatments. Physical restraints should be avoided because on the one hand they have no effect and on the other hand they raise an ethical problem. The architects have provided spaces in the institutions allowing unrestricted walking. These spaces should be bright, spacious, attractive, risk-free and create a sense of security.

The planning of physical activities (gymnastics, walks) must complete the care program, with dance and singing programs as well. It is strongly advised to monitor the nutritional status of these people, whose energy expenditure and water loss are significant. The room must be arranged so that the patient can find familiar landmarks (small pieces of furniture, family and home photographs, etc.).

Repetitive behaviors

Repetitive behaviors are, like wandering, specific to demented states and often concern the same people. There are two forms of repetitive behavior:

1. Risk-free behaviors

These people are constantly doing and undoing (eg emptying and filling a cupboard, making and undoing a bed, etc.). These activities are favored by boredom and the absence of activities (which is somewhat paradoxical…). The programs proposed to reduce ambulation are quite suitable in this case.

2. Risky behaviors

These are often behaviors of self-mutilation (eg repeated scratching of the face with the fingernails) whose intention is difficult to understand. This behavior can temporarily stop if an affective derivative is offered: caresses, massages or animal therapy.

Runaways are behavioral problems feared by health professionals. They occur most often in the weeks following entry into an institution and tend to subside after a period of adaptation. It would seem that the patient wants to flee a place because it is inhospitable to him, even hostile. However, it is difficult to offer closed structures for security reasons (risk of fire) and psychological reasons (feelings of being in a prison). Some institutions suggest placing exits in dark areas or concealing them. We can also prevent the risk of running away by arranging the environment with familiar objects to familiarize the patient with his environment and improve his well-being.

Disinhibition

It results in impulsive and inappropriate behavior. The patient cannot maintain the type of social behavior he had before. Symptoms include:

• the cries;
• euphoria;
• verbal abuse;
• physical violence directed at others or objects;
• self-destructive behaviors;
• sexual disinhibition;
• motor restlessness;
• intrusive behaviors;
• impulsiveness;
• wandering.

Shoplifting, gambling addiction, compulsive shopping can lead to financial and social problems in patients with disinhibition. Patients with impaired judgment are more likely to consume alcohol or drugs excessively.

Intrusive behaviors

The intrusive behavior manifests itself in gestures of protest, impatience, clinging or jostling. These behaviors have a prevalence of about 40% in dementia, and do not seem to depend on the severity of the cognitive and functional deficit.

Sleep disorders

These disorders end up exhausting the family caregivers, leading them to place the patient in a medical institution. The doctor must inform the relative of the physiological changes in sleep (lengthened sleep onset, jerky sleep, reduced quality of sleep, etc.) that accompany dementia. Difficulties falling asleep are caused by anxiety disorders, while early awakenings evoke depression.

The use of sleeping pills should be temporary and of short duration. Some non-drug measures can improve sleep disturbances.

Vocalization behaviors

These verbal expressions, often brief but repetitive, are more frequent when the patient is isolated, in the evening between meals and going to bed, or in the morning between waking up and getting up. It is difficult for caregivers to determine the causes and reasons for these cries. In the absence of specific causes (pain, hallucinations, etc.), the cries are attributed to dementia.

Treating these symptoms is difficult. Certain non-drug approaches sometimes prove effective: correction of sensory deficits, reduction of sensory stimulation (noise, light, cognitive activity), getting the patient to talk about the difficulties he is experiencing in the institution (his daily life, his isolation) , adopt a calm and reassuring attitude, communicate non-verbally (caress the patient’s hands and face), offer massage sessions.

Atypical antipsychotics present but seem, according to some doctors, to be less well tolerated than selective serotonin reuptake inhibitor type antidepressants (eg Paxil).

The problems of identification

Unlike hallucinations (which occur in the absence of external stimuli), identification disorders are due to errors in the perception of external stimuli. There are four forms:

• ‘ghost boarder’ syndrome: presence of people inside the patient’s home (about 5% are convinced that people appearing on television are present in the room);
• self-identification disorder: it is often manifested by the fact that the subject does not recognize himself in a mirror; (about 4% of patients);
• other people’s identification disorder: the patient takes people for other people (about 12%);
• misidentification of events.

In 1990, Ellis and Young distinguished three forms of delusional identification disorder: Capgras syndrome .

Fregoli syndrome is a type of hyperidentification characterized by the fact that patients are convinced that individuals wishing to harm or influence them disguise themselves to assume the identity of other people. In many ways, Fregoli syndrome can be like the normal experience.

When a non-demented subject expects to meet a person, he may, for a brief moment, take a stranger for the person he was expecting, but this perception is quickly corrected by noting divergent facts. A patient with Fregoli syndrome will attribute these divergent facts to the notion of a disguise.

Intermetamorphosis delusion describes a situation in which one person’s physical appearance is perceived as that of another.

Many parents and caregivers find their own ways to cope with the difficulties of identification. It is important to understand that what works well with one person may not be as effective with another. In some cases, humor will be preferred while in others, comfort or diversion will lead to greater success.

Care

What are the actions to take when faced with a person suffering from dementia accompanied by psychological and behavioral disorders?

Anxiety

Anxiety often causes physical manifestations related to anxiety. In some cases, it can result in delusional states during which the elder will accuse those around them of theft, for example.

In the patient, anxiety results in momentary disturbances which concern both the body and the consciousness. It becomes abnormal when it occurs for no apparent reason and permanently.

At the psychological level, it results in a feeling of inner malaise, internal tensions, difficulty concentrating, threat or depersonalization. At the physical level, anxiety results in an increase in heart rate, respiratory rate and sweating. From the behavioral point of view, we observe agitation, incessant movements, clenching of the hands and aggressiveness.

How to deal with this type of problem?
– Prescribe a short-lived anxiolytic.
– Use relaxation techniques to relax the muscles and the mind.
– Identify the triggering factor.
– Reassure the person by speaking calmly.
– Try to determine the origin of the agitation, taking into account the person’s biography.

Agitation and aggression

Agitation is manifested above all by incessant wanderings, diurnal or nocturnal, messy activities, akathisia, running away caused by temporal and spatial disorientation, repeated manual movements (eg scratching, folding of clothes). Two-thirds of patients show signs of institutional agitation. This percentage reaches 90% in those suffering from dementia.

Aggression, whether verbal or physical, often has an unusual character that surprises those around you. The latter dreads it, because it is often unpredictable and difficult to control. Aggression refers to all activities aimed at harming an individual or an object directly or indirectly. This behavioral disorder generally takes place during a relational exchange, in particular when washing, dressing, eating or going to bed.

A distinction must be made between aggressive and non-aggressive behaviors, which are expressed verbally and non-verbally (physically): – motor agitation: aimless walk, nocturnal wandering;
– physical aggression: throwing or destroying objects, making inappropriate gestures, biting, spitting, scratching, kicking, beating another person;
– verbal aggression: speaking loudly, shouting, swearing, using rude words, threatening, accusing, making unusual noises, complaining, whining, making repeated demands;
– passive aggression: delaying, avoiding or refusing help.

How to prevent or mitigate this type of behavior?
– Prescribe pharmacological treatment (neuroleptics, lithium, carbamazepine, buspirone, antidepressants, short-lived benzodiazepines), particularly in the event of an acute situation of agitation and/or aggressiveness accompanying dementia.
– Try to restore an activity during the day (in case of nocturnal restlessness).
– Adopt a serene attitude and a soothing tone of voice.
– Stand facing the person and at the same height.
– Express yourself in simple words.
– Establish physical contact by staying close to the patient or holding their hand, especially when there are visitors in the house.
– Listen and decode non-verbal language.
– Name yourself and name the person.
– Give a snack at the time of the crisis of nocturnal agitation.
– Leave a little light in the room in case of nocturnal agitation.
– Install the person in a room for two to reduce anxiety in the event of nocturnal restlessness in an institution.
– Propose a relaxing activity (walking, listening to music, isolation for some time in the room).
– Try to establish routines in the activities of daily living (bathing, meals).
– Avoid placing the patient near a source of noise (washing machine, washing machine) which could cause agitation.
– De-dramatize situations that could humiliate or make the patient feel guilty (in the event of aggressive behaviour).

Don’ts:
– Do not insist if the person refuses to cooperate.
– Avoid using the subject “on”.
– Do not respond to aggression with aggression.
– Do not adopt an infantilizing attitude.
– Do not try to reason with the patient with arguments that go beyond the possibilities of understanding.
– Do not argue with her by contradicting her.
– Do not offer him things that are too difficult for his remaining abilities.
– Do not express your frustration.
– Do not re-discuss events that led to aggressive behavior.

After having tackled the problem, you must try to determine the origin of the conflict: look for the triggering elements showing significant frustration (agitation and/or aggressiveness in a demented state). Look for bodily, psychological or psychosocial causes and then treat them.

Here are some questions to ask yourself in order to identify the factors if possible:
– Does the patient have a headache? 
– Is he particularly tired?
– Is he constipated?
– Does he sleep badly?
– Are his clothes inappropriate (too warm, tight)? 
– Is he too stimulated by the environment (continuous television, radio at too high a volume)? 
– Is he upset by a new environment (bedroom, kitchen) in which he has lost his bearings?
– Is he more restless when he is alone or, on the contrary, when there are people around?
– Does he feel compelled to perform an activity against his will?

Agitation, confusional states and end of life

Agitation is common in elderly subjects at the end of life. The causes come from several factors, hence the need to seek a curable cause or poorly relieved pain, or to remove drugs that are not essential.

Elements to look for in a patient at the end of life: 
– Unrelieved pain.
– Urinary retention.
– Dry mouth, dehydration.
– Confusion caused by medication (neuroleptics, morphine, antiemetic, anticholinergic).
– Metabolic disorders (hypoglycaemia).
– Neurological origin (eg brain metastasis).
– Psychological origin (anxiety, conflict).

Psychological Behavioral Symptoms References

Pancrazi MP, Métais P. Alzheimer’s disease, diagnosis of psychological and behavioral disorders. Medical Press 2005; 34(9): 661-6.

Brocker P et al. Psychological and behavioral symptoms of dementia: description and management. The Journal of Geriatrics, Volume 30, N°4 April 2005

Cummings JL, Mega MS, Gray K, Rosemberg-Thompson S, Gornbein T. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-14.

Conn D, Thorpe L. Assessment of behavioral and psychological symptoms associated with dementia. Can J Neurol Sci. 2007 Mar;34 Suppl 1:S67-71.

Benoit M, Staccini P, Brocker P, Benhamidat T, Bertogliati C, Lechowski L, Tortrat D, Robert PH. Behavioral and psychological symptoms in Alzheimer’s disease: results of the REAL.FR study Rev Med Interne. 2003 Oct;24 Suppl 3:319s-324s.