People are living for longer, and it is therefore increasingly likely to know someone affected by dementia. In Spain there are more than 700,000 cases and this number is expected to rise in the coming years, due to the aging of the population.

Cognitive impairment (dementia) is disabling for those affected by it, and is devastating for the family members and caregivers. It is one of the main causes of disability and dependence in the elderly.

It is easy to suspect dementia when there are memory lapses or disorientation, but it is more challenging when the main symptoms are only changes are in character or in behavior.

Behavioral and Psychological Symptoms of Dementia

The term Behavioral and Psychological Symptoms of Dementia (BPSD) is used to define the behavioral reactions and psychological symptoms that occur in people with cognitive impairment of any origin. They are frequent and may be due to the cognitive impairment itself, or they can be the consequence of intercurrent medical, psychological or environmental condition.

Behavioral symptoms can be identified through observation, while psychological symptoms are identified through interaction with the affected person. It is typically the caregiver or the family member who identifies the psychological symptoms.

Different Behavioral and Psychological Symptoms of Dementia are described below:

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  • Depression: Individuals appear sad and dull, and may express feelings of being a burden.
  • Irritability: Individuals may be moody, impatient and intolerant. They may overreact or lose temper with trivial things.
  • Fear: Individuals feel unconfident, apprehensive, or insecure
  • Anxiety: Internal tension, which does not allow to be calm.
  • Restlessness: Inability to stand still due to anxiety and internal tension.
  • Nervousness: Restlessness as a consequence of anxiety and internal tension.
  • Agitation: Individuals feel intensely restless and worried, and are unable to calm down. They may react aggressively.


  • Verbal: They may insult, threaten or raise their tone.
  • Physical
    • Against people: They may hit, push or spit on other people.
    • Against objects: They may throw things, slam the door, hit furniture or other objects, etc.
  • Oppositionism: They present aggressive resistance to basic activities such as grooming, eating or dressing.
  • Apathy: Loss of interest and motivation. There is lack of excitement and enthusiasm.
  • Changes in eating behavior:
    • Loss of appetite: Loss of the drive to eat.
    • Increased appetite: There is an increased desire for food.
    • Hyperphagia: Eating more food than necessary. Binge eating. Individuals may put excessive food into their mouth, which can induce choking.
    • Hyperorality: Individuals have hyperphagia and may want to eat unhealthy foods, limited food groups (typically carbohydrates), or even inedible material.
  • Sleep changes: Different sleep changes may appear in people with dementia.
    • Hypersomnia: There is excessive sleepiness.
    • Insomnia: There is lack of sleep.
    • Fragmented sleep: Sleep is interrupted and discontinuous due to awakenings.
    • Loss of sleep-wake cycle: This is when the biological clock is not synchronized with the environment. In the extreme case in which there is a total inversion of the biological rhythm, the individuals are sleepy during the day and active at night.
    • REM sleep behavioral disturbance: Affected individuals move, talk and live out their dreams, sometimes in a violent manner (kicking, punching or screaming). Unintentional harm to the bed partner or self harm can occur. REM sleep behavioral disturbance is usually suspected by a third party.
  • Personality or character change: Individuals may lose their essence, and act in a way that is different to the old self. They can appear more fearful and insecure or, on the contrary, more impolite and ruder. Being more impatient, distrustful, rigid, insensitive, or apathetic than usual are other possible personality changes.
  • Cognitive rigidity: Individuals become less and less mentally flexible and show little ability to adapt to circumstances or changes of routine. They want things to be done their way.
  • Loss of empathy: Individuals lose interest in the feelings of others and may show superficial emotion.
  • Loss of social cognition: Individuals lose the sense of social values and the ability to adapt to the social world. They may steal food from other people’s plate, or may use their fingers to eat. They may appropriate other people’s belonging.
  • Impulsivity: Lack of foresight or social tact in language, body language or other behaviors.


  • Behavioral disinhibition:
    • Repetitive compulsive behaviors.
    • Sexual disinhibition behaviors: Increased sexual behavior with loss of modesty.
  • Disinhibition of thoughts:
    • Becoming more extroverted and impulsive.
    • Making comments that are out of place or socially inappropriate.
    • Using inappropriate language.
  • Lack of judgment: Loss of the ability to make decisions. Individuals lose the capacity to take into account and to evaluate different factors that are necessary for decision making.


Erroneous beliefs that are tenaciously hold without evidence to support them. Things are not perceived as they are.

  • Persecutory delusion: Individuals are preoccupied that they are being conspired against, followed or harmed.
  • Delusion of poisoning: Believing that they are being poisoned, typically through food or medication.
  • Delusional misidentification:
    • Typically believing that the identity of a loved one has been supplanted by an impostor. This type of misidentification is called Capgras syndrome.
    • Not identifying their home as theirs, and thinking it is someone else's home.
  • Jealousy delusion: Believing that the partner or lover is unfaithful.
  • Delusion of theft: Individuals believe they are being robbed because they cannot locate their belongings.


Perceptions that involve the senses, in the absence of external stimuli. They are felt like real, but cannot be confirmed by anyone else. They can cause positive or negative experiences. There are different types of hallucinations:

  • Visual: Individuals perceive images of something that is not there. Misidentifying an object for a person or for an animal can be a mistake instead of a hallucination, typically in the context of low vision.
  • Auditory: The person hears something that is not real. It can be a voice, a sound, a melody...
  • Olfactory: The person perceives a smell that cannot be confirmed by anyone else.
  • Tactile: Individuals experience tactile sensations through the body without anything touching them. They may feel bugs crawling around them or feel pressure on their skin or organs.
  • Childish attitude: Seemingly childish behaviors: tantrums, outbursts, opposition, irrationality, manipulation.
  • Follower behaviors of the caregiver: Following the caregiver like a shadow. Search for constant attention, security and comfort.
  • Wandering: Individuals roam around and can potentially get lost. In people with physical or balance limitations, there is also a risk of fall.
  • Repeated and stereotyped actions
    • Vocalizations: utterances that are typically repetitive and loud. They can consist of sounds, words or small phrases.
    • Repeated actions such as repeatedly taking off the belt or moving things around.
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It is important to acknowledge that dementia is not only memory loss and disorientation. There are in fact many other symptoms that are very frequent and can be even more disabling than amnesia itself.

Recognizing the Behavioral and Psychological Symptoms of Dementia is key to early identification of cognitive impairment and to prompt intervention. It is also essential to guide and support family members and caregivers in the management of the affected persons.

About the author

María Isabel Zamora is a physician with a double specialty in Psychiatry and Neurology. She has experience in the care of patients in general psychiatry consultations, and in a more specialized way, in the care of patients who combine psychiatric and neurological symptoms. She has worked with psychogeriatric patients and patients with functional diversity. She has experience in cognitive impairment, psychological and behavioral symptoms of dementia, psychiatric symptoms related to neurological disorders or chronic pain, autism, ADHD, adaptive disorders, depression, anxiety, addictions, bipolar disorder, obsessive-compulsive disorder, sleep disorders, eating disorders, etc.

Dra. María Isabel Zamora
Division of Medicine
Dra. María Isabel Zamora
Adults and adolescents
Languages: English, French and Spanish
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