Michael J. Passmore, MD, FRCPC, Clinical Assistant Professor, Department of Psychiatry, Geriatric Psychiatry Program, University of British Columbia, Vancouver, BC.

The following review uses case studies to illustrate the importance of a biopsychosocial approach to the assessment and management of behavioural and psychological symptoms of dementia (BPSD). Practical BPSD assessment strategies are reviewed, in addition to evidence-based and guideline-supported recommendations for acute and long-term BPSD management.
Key words: dementia, behaviour, agitation, antipsychotic, memantine.

Shailaja Shah, MD, Clinical Assistant Professor, Assistant Director Geriatric Psychiatry Fellowship, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Gautam Rohatgi, DO, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Daniela Ganescu, MD, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.

Alzheimer’s disease (AD) is the most common cause of dementia, affecting nearly 18 million people around the world. Alzheimer’s disease is characterized by cognitive, functional, and behavioural decline. As the condition progresses the affected individual becomes increasingly dependent on others for assistance in performing all activities of daily living. Neuropsychiatric symptoms (NPS) such as agitation, psychosis, and apathy are very common in dementia and especially in AD. Agitation and apathy contribute to a tremendous amount of caregiver distress. Treatment guidelines recommend utilizing nonpharmacologic behavioural approaches in all instances. When behavioural interventions fail or when the behaviour is severe, medications are recommended. At present, no psychotropic agent presently available within the United States is FDA-approved for use in dementia complicated with behaviour disturbance.
Key words: agitation, apathy, behaviour interventions, atypical antipsychotics, dementia.

Dorothy A Forbes, RN, PhD, CIHR New Investigator, Associate Professor, College of Nursing, University of Saskatchewan, Saskatoon, SK.
Shelley Peacock, RN, MN, Faculty Member, Saskatchewan Institute of Applied Science and Technology, Saskatoon, SK.
Debra Morgan, RN, PhD, Associate Professor, Institute of Agricultural, Rural, and Environmental Health, University of Saskatchewan, Saskatoon, SK.

Strategies such as simulated presence therapy, pet therapy, light therapy, validation therapy, music, massage, therapeutic touch, aromatherapy, and multisensory stimulation have shown promising results in decreasing physical aggression, physical nonaggression, verbal aggression, and verbal nonaggression in older adults with dementia. Further research is needed to identify which strategies are most effective in managing symptoms of agitation associated with the different types of dementia and at different levels of cognitive impairment.

Key words: Alzheimer’s disease, dementia, nonpharmacological strategies, agitation, aggression, behaviour.

Eileen P. Sloan, PhD, MD
Resident in Psychiatry,
Department of Psychiatry,
University of Toronto.

Introduction
Agitation is an aspect of dementia that can have serious emotional, medical and health-care system consequences. It results in decreased quality of life for both patient and caregiver and is often cited as the reason for the patient being admitted to a long-term care facility. Within the nursing home setting, agitation may often result in increased use of physical and/or chemical restraints, with concomitant problems such as physical injury and falls. Medical care of the agitated patient can be compromised and nursing staff is required to spend greater amounts of time caring for the agitated patient.

Definition and Prevalence
Allen (1999) points out that "agitation" is not a diagnosis but refers to a constellation of symptoms.¹ Cohen-Mansfield and Billing (1986)² define agitation as "inappropriate verbal, vocal or motor activity unexplained by apparent needs or confusion." These authors divide the symptoms of agitation into three: aggressive behaviours (hitting, kicking, verbal aggression, spitting); inappropriate physically non-aggressive behaviours (pacing, repetitious mannerisms, robing and disrobing); and inappropriate verbal agitated behaviours (screaming, complaining, constant demands for attention).