Skip to main navigation menu Skip to main content Skip to site footer

Review article: Biomedical intelligence

Vol. 149 No. 4344 (2019)

Interventional psychiatry in the management of behavioural and psychological symptoms of dementia: a qualitative review

  • Kevin Swierkosz-Lenart
  • Jean-Frédéric Mall
  • Armin von Gunten
Cite this as:
Swiss Med Wkly. 2019;149:w20140



“Behavioural and psychological symptoms of dementia” (BPSD) refers to a heterogeneous group of clinical manifestations related to dementia, including apathy, depression, anxiety, delusions, hallucinations, sexual or social disinhibition, sleep-wake cycle disturbances, aggression, agitation and other behaviours considered inappropriate. Because of the complexity and heterogeneity of BPSD, as well as the fragility and multimorbidity of the elderly, pharmacological treatment appears to be limited in terms of safety and efficacy, and nonpharmacological therapies are today considered the first choice. There is growing evidence that interventional approaches such as electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS) could be safe and efficient options for several psychiatric illnesses in a population presenting resistance to and/or intolerance of pharmacotherapy.


The aim of the present work is to provide a qualitative review of the state of the art in interventional psychiatry in the treatment of BPSD. A particular focus will be on depression and agitation, which represent major stressors on caregivers and a primary cause of institutionalisation.


ECT is probably the most promising interventional procedure needing further investigation in order to obtain specific protocols and a consensus on indications. Preliminary data on rTMS, tDCS, and VNS are encouraging although randomised controlled trials to investigate and compare their efficacy in the treatment of BPSD are still lacking. Their feasibility profile could represent an important advantage over ECT. DBS could represent a very effective therapy for behavioural disorders, but knowledge of the precise neuroanatomical targets for BPSD is currently too limited to justify this invasive approach.


  1. Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. 2015;350(mar02 7):h369. doi:.
  2. Tible OP, Riese F, Savaskan E, von Gunten A. Best practice in the management of behavioural and psychological symptoms of dementia. Ther Adv Neurol Disorder. 2017;10(8):297–309. doi:.
  3. Hersch EC, Falzgraf S. Management of the behavioral and psychological symptoms of dementia. Clin Interv Aging. 2008;2:611–21. doi:.
  4. Selvadurai MI, Waxman R, Ghaffar O, Fischler I. Efficacy and safety of maintenance electroconvulsive therapy for sustaining resolution of severe aggression in a major neurocognitive disorder. BMJ Case Rep. 2018;2018:bcr-2017-222100. doi:.
  5. Canevelli M, Adali N, Cantet C, Andrieu S, Bruno G, Cesari M, et al. ICTUS/DSA Group. Impact of behavioral subsyndromes on cognitive decline in Alzheimer’s disease: data from the ICTUS study. J Neurol. 2013;260(7):1859–65. doi:.
  6. Nourhashémi F, Andrieu S, Sastres N, Ducassé JL, Lauque D, Sinclair AJ, et al. Descriptive analysis of emergency hospital admissions of patients with Alzheimer disease. Alzheimer Dis Assoc Disord. 2001;15(1):21–5. doi:.
  7. Savaskan E, Bopp-Kistler I, Buerge M, Fischlin R, Georgescu D, Giardini U, et al. Empfehlungen zur Diagnostik und Therapie der behavioralen und psychologischen Symptome der Demenz (BPSD) [Therapy guidelines for the behavioural and psychological symptoms of dementia]. Praxis (Bern). 2014;103:135–48. Articlein German. doi:.
  8. Mishra BR, Sarkar S, Praharaj SK, Mehta VS, Diwedi S, Nizamie SH. Repetitive transcranial magnetic stimulation in psychiatry. Ann Indian Acad Neurol. 2011;14(4):245–51. doi:.
  9. Helmich RC, Siebner HR, Bakker M, Münchau A, Bloem BR. Repetitive transcranial magnetic stimulation to improve mood and motor function in Parkinson’s disease. J Neurol Sci. 2006;248(1-2):84–96. doi:.
  10. Kekic M, Boysen E, Campbell IC, Schmidt U. A systematic review of the clinical efficacy of transcranial direct current stimulation (tDCS) in psychiatric disorders. J Psychiatr Res. 2016;74:70–86. doi:.
  11. Holtzheimer PE, Mayberg HS. Deep Brain Stimulation for Psychiatric Disorders. Annu Rev Neurosci. Author manuscript available in PMC 2015 Apr 29. Published in final edited form as. Annu Rev Neurosci. 2011;34(1):289–307. doi:.
  12. Bari AA, Mikell CB, Abosch A, Ben-Haim S, Buchanan RJ, Burton AW, et al. Charting the road forward in psychiatric neurosurgery: proceedings of the 2016 American Society for Stereotactic and Functional Neurosurgery workshop on neuromodulation for psychiatric disorders. J Neurol Neurosurg Psychiatry. 2018;89(8):886–96. doi:.
  13. Rong P, Liu J, Wang L, Liu R, Fang J, Zhao J, et al. Effect of transcutaneous auricular vagus nerve stimulation on major depressive disorder: a nonrandomized controlled pilot study. J Affect Disord. 2016;195:172–9. doi:.
  14. Albert U, Maina G, Aguglia A, Vitalucci A, Bogetto F, Fronda C, et al. Vagus nerve stimulation for treatment-resistant mood disorders: a long-term naturalistic study. BMC Psychiatry. 2015;15(1):64. doi:.
  15. Feast A, Moniz-Cook E, Stoner C, Charlesworth G, Orrell M. A systematic review of the relationship between behavioral and psychological symptoms (BPSD) and caregiver well-being. Int Psychogeriatr. 2016;28(11):1761–74. doi:.
  16. Rosa MA, Lisanby SH. Somatic Treatments for Mood Disorders. Neuropsychopharmacology. 2012;37(1):102–16. doi:.
  17. Salik I, Marwaha R. Electroconvulsive Therapy. Treasure Island, FL: StatPearls Publishing; 2019.
  18. Wachtel LE. Treatment of catatonia in autism spectrum disorders. Acta Psychiatr Scand. 2019;139(1):46–55. doi:.
  19. Wachtel LE, Shorter E, Fink M. Electroconvulsive therapy for self-injurious behaviour in autism spectrum disorders: recognizing catatonia is key. Curr Opin Psychiatry. 2018;31(2):116–22. doi:.
  20. Kellner CH, Fink M, Knapp R, Petrides G, Husain M, Rummans T, et al. Relief of expressed suicidal intent by ECT: a consortium for research in ECT study. Am J Psychiatry. 2005;162(5):977–82. doi:.
  21. Kamel H, Cornes SB, Hegde M, Hall SE, Josephson SA. Electroconvulsive therapy for refractory status epilepticus: a case series. Neurocrit Care. 2010;12(2):204–10. doi:.
  22. Shin HW, O’Donovan CA, Boggs JG, Grefe A, Harper A, Bell WL, et al. Successful ECT treatment for medically refractory non-convulsive status epilepticus in pediatric patient. Seizure. 2011;20(5):433–6. doi:.
  23. Shah N, Pande N, Bhat T, Murke M, Andrade C. Maintenance ECT as a therapeutic approach to medication-refractory epilepsy in an adult with mental retardation: case report and review of literature. J ECT. 2012;28(2):136–40. doi:.
  24. Sanacora G, Mason GF, Rothman DL, Hyder F, Ciarcia JJ, Ostroff RB, et al. Increased cortical GABA concentration in depressed patients receiving ECT. Am J Psychiatry. 2003;160(3):577–9. doi:.
  25. International Psychogeriatric Association. The IPA complete guides to behavioral and psychological symptoms of dementia. Milwaukee, WI: International Psychogeriatric Association, 2010
  26. Takano H, Motohashi N, Uema T, Ogawa K, Ohnishi T, Nishikawa M, et al. Changes in regional cerebral blood flow during acute electroconvulsive therapy in patients with depression. Br J Psychiatry. 2007;190(1):63–8. doi:.
  27. Nobler MS, Oquendo MA, Kegeles LS, Malone KM, Campbell CC, Sackeim HA, et al. Decreased regional brain metabolism after ECT. Am J Psychiatry. 2001;158(2):305–8. doi:.
  28. George MS, Aston-Jones G. Noninvasive techniques for probing neurocircuitry and treating illness: vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). Neuropsychopharmacology. 2010;35(1):301–16. doi:.
  29. Riva-Posse P, Hermida AP, McDonald WM. The Role of Electroconvulsive and Neuromodulation Therapies in the Treatment of Geriatric Depression. Psychiatr Clin North Am. 2013;36(4):607–30. doi:.
  30. Tew JD Jr, Mulsant BH, Haskett RF, et al. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry. 1999;156(12):1865–70.
  31. Flint AJ, Gagnon N. Effective use of electroconvulsive therapy in late-life depression. Can J Psychiatry. 2002;47(8):734–41. doi:.
  32. Greenberg RM, Kellner CH. Electroconvulsive therapy: a selected review. Am J Geriatr Psychiatry. 2005;13(4):268–81. doi:.
  33. Dols A, Bouckaert F, Sienaert P, Rhebergen D, Vansteelandt K, Ten Kate M, et al. Early- and Late-Onset Depression in Late Life: A Prospective Study on Clinical and Structural Brain Characteristics and Response to Electroconvulsive Therapy. Am J Geriatr Psychiatry. 2017;25(2):178–89. doi:.
  34. Aksay SS, Hausner L, Frölich L, Sartorius A. Severe agitation in severe early-onset Alzheimer’s disease resolves with ECT. Neuropsychiatr Dis Treat. 2014;10:2147–51.
  35. Fazzari G, Marangoni C, Benzoni O. Maintenance ECT for the treatment and resolution of agitation in Alzheimer’s dementia. Journal of Psychopathology. 2015;21:159–60.
  36. Grant JE, Mohan SN. Treatment of agitation and aggression in four demented patients using ECT. J ECT. 2001;17(3):205–9. doi:.
  37. Sutor B, Rasmussen KG. Electroconvulsive therapy for agitation in Alzheimer disease: a case series. J ECT. 2008;24(3):239–41. doi:.
  38. Wu Q, Prentice G, Campbell JJ. ECT treatment for two cases of dementia-related aggressive behavior. J Neuropsychiatry Clin Neurosci. 2010;22(2):247.e10–247.e11. doi:.
  39. Borisovskaya A, Augsburger J, Pascualy M. Electroconvulsive therapy for frontotemporal dementia with comorbid major depressive disorder. J ECT. 2014;30(4):45–6. doi:.
  40. Bang J, Price D, Prentice G, Campbell JJ. ECT treatment for two cases of dementia-related pathological yelling. J Neuropsychiatry Clin Neurosci. 2008;20(3):379–80. doi:.
  41. Takahashi S, Mizukami K, Yasuno F, Asada T. Depression associated with dementia with Lewy bodies (DLB) and the effect of somatotherapy. Psychogeriatrics. 2009;9(2):56–61. doi:.
  42. Acharya D, Harper DG, Achtyes ED, Seiner SJ, Mahdasian JA, Nykamp LJ, et al. Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia. Int J Geriatr Psychiatry. 2015;30(3):265–73. doi:.
  43. Grover S, Sahoo S, Rabha A, Koirala R. ECT in schizophrenia: a review of the evidence. Psychiatr Danub. 2019;31(1):62–8.
  44. Verwijk E, Comijs HC, Kok RM, Spaans HP, Tielkes CE, Scherder EJ, et al. Short- and long-term neurocognitive functioning after electroconvulsive therapy in depressed elderly: a prospective naturalistic study. Int Psychogeriatr. 2014;26(2):315–24. doi:.
  45. Lima BR, Alencar AAD, Carneiro DM, et al. The efficiency of electroconvulsive therapy in the treatment of depression in the elderly. Int Arch Med. 2015;8:1–4.
  46. Roth Y, Amir A, Levkovitz Y, Zangen A. Three-dimensional distribution of the electric field induced in the brain by transcranial magnetic stimulation using figure-8 and deep H-coils. J Clin Neurophysiol. 2007;24(1):31–8. doi:.
  47. Fitzgerald PB, Fountain S, Daskalakis ZJ. A comprehensive review of the effects of rTMS on motor cortical excitability and inhibition. Clin Neurophysiol. 2006;117(12):2584–96. doi:.
  48. Taylor R, Galvez V, Loo C. Transcranial magnetic stimulation (TMS) safety: a practical guide for psychiatrists. Australas Psychiatry. 2018;26(2):189. doi:.
  49. Gaynes BN, Lloyd SW, Lux L, Gartlehner G, Hansen RA, Brode S, et al. Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and meta-analysis. J Clin Psychiatry. 2014;75(5):477–89. doi:.
  50. Reddy MS, Starlin Vijay M. Repetitive Transcranial Magnetic Stimulation for Depression: State of the Art. Indian J Psychol Med. 2017;39(1):1–3. doi:.
  51. Perera T, George MS, Grammer G, Janicak PG, Pascual-Leone A, Wirecki TS. The clinical TMS society consensus review and treatment recommendations for TMS therapy for major depressive disorder. Brain Stimul. 2016;9(3):336–46. doi:.
  52. Broadbent HJ, van den Eynde F, Guillaume S, Hanif EL, Stahl D, David AS, et al. Blinding success of rTMS applied to the dorsolateral prefrontal cortex in randomised sham-controlled trials: a systematic review. World J Biol Psychiatry. 2011;12(4):240–8. doi:.
  53. Wu Y, Xu W, Liu X, Xu Q, Tang L, Wu S. Adjunctive treatment with high frequency repetitive transcranial magnetic stimulation for the behavioral and psychological symptoms of patients with Alzheimer’s disease: a randomized, double-blind, sham-controlled study. Shanghai Jingshen Yixue. 2015;27(5):280–8.
  54. Bersani FS, Minichino A, Enticott PG, Mazzarini L, Khan N, Antonacci G, et al. Deep transcranial magnetic stimulation as a treatment for psychiatric disorders: A comprehensive review. Eur Psychiatry. 2013;28(1):30–9. doi:.
  55. Stanford AD, Sharif Z, Corcoran C, Urban N, Malaspina D, Lisanby SH. rTMS strategies for the study and treatment of schizophrenia: a review. Int J Neuropsychopharmacol. 2008;11(04):563–76. doi:.
  56. Padala PR, Padala KP, Lensing SY, Jackson AN, Hunter CR, Parkes CM, et al. Repetitive transcranial magnetic stimulation for apathy in mild cognitive impairment: A double-blind, randomized, sham-controlled, cross-over pilot study. Psychiatry Res. 2018;261:312–8. doi:.
  57. Wagner T, Valero-Cabre A, Pascual-Leone A. Noninvasive human brain stimulation. Annu Rev Biomed Eng. 2007;9(1):527–65. doi:.
  58. Pelletier SJ, Cicchetti F. Cellular and Molecular Mechanisms of Action of Transcranial Direct Current Stimulation: Evidence from In Vitro and In Vivo Models. Int J Neuropsychopharmacol. 2015;18(2):pyu047. doi:.
  59. Dell’Osso, B, Altamura, AC. Transcranial brain stimulation techniques for major depression: should we extend TMS lessons to tDCS? clinical practice and epidemiology in mental health. CP EMH. 2014;10:92–3.
  60. Rigonatti SP, Boggio PS, Myczkowski ML, Otta E, Fiquer JT, Ribeiro RB, et al. Transcranial direct stimulation and fluoxetine for the treatment of depression. Eur Psychiatry. 2008;23(1):74–6. doi:.
  61. Brunoni AR, Moffa AH, Sampaio-Junior B, Borrione L, Moreno ML, Fernandes RA, et al. ELECT-TDCS Investigators. Trial of Electrical Direct-Current Therapy versus Escitalopram for Depression. N Engl J Med. 2017;376(26):2523–33. doi:.
  62. Loo CK, Alonzo A, Martin D, Mitchell PB, Galvez V, Sachdev P. Transcranial direct current stimulation for depression: 3-week, randomised, sham-controlled trial. Br J Psychiatry. 2012;200(1):52–9. doi:.
  63. Shiozawa P, da Silva ME, Cordeiro Q, Fregni F, Brunoni AR. Transcranial direct current stimulation (tDCS) for the treatment of persistent visual and auditory hallucinations in schizophrenia: a case study. Brain Stimul. 2013;6(5):831–3. doi:.
  64. Brunoni AR, Amadera J, Berbel B, Volz MS, Rizzerio BG, Fregni F. A systematic review on reporting and assessment of adverse effects associated with transcranial direct current stimulation. Int J Neuropsychopharmacol. 2011;14(8):1133–45. doi:.
  65. Ishibashi R, Mima T, Fukuyama H, Pobric G. Facilitation of Function and Manipulation Knowledge of Tools Using Transcranial Direct Current Stimulation (tDCS). Front Integr Nuerosci. 2018;11:37. doi:.
  66. Binney RJ, Zuckerman BM, Waller HN, Hung J, Ashaie SA, Reilly J. Cathodal tDCS of the Bilateral Anterior Temporal Lobes Facilitates Semantically-Driven Verbal Fluency. Neuropsychologia. 2018;111:62–71. doi:.
  67. Holtzheimer PE, Husain MM, Lisanby SH, Taylor SF, Whitworth LA, McClintock S, et al. Subcallosal cingulate deep brain stimulation for treatment-resistant depression: a multisite, randomised, sham-controlled trial. Lancet Psychiatry. 2017;4(11):839–49. doi:.
  68. Laxton AW, Tang-Wai DF, McAndrews MP, Zumsteg D, Wennberg R, Keren R, et al. A phase I trial of deep brain stimulation of memory circuits in Alzheimer’s disease. Ann Neurol. 2010;68(4):521–34. doi:.
  69. Daban C, Martinez-Aran A, Cruz N, Vieta E. Safety and efficacy of Vagus Nerve Stimulation in treatment-resistant depression. A systematic review. J Affect Disord. 2008;110(1-2):1–15. doi:.
  70. Fang J, Rong P, Hong Y, Fan Y, Liu J, Wang H, et al. Transcutaneous Vagus Nerve Stimulation Modulates Default Mode Network in Major Depressive Disorder. Biol Psychiatry. 2016;79(4):266–73. doi:.
  71. Cimpianu CL, Strube W, Falkai P, Palm U, Hasan A. Strube1 W, Falkai P, Palm U, Hasan A. Vagus nerve stimulation in psychiatry: a systematic review of the available evidence. J Neural Transm (Vienna). 2017;124(1):145–58. doi:.
  72. O’Reardon JP, Cristancho P, Peshek AD. Vagus Nerve Stimulation (VNS) and Treatment of Depression: To the Brainstem and Beyond. Psychiatry (Edgmont Pa). 2006;3(5):54–63.
  73. Berry SM, Broglio K, Bunker M, Jayewardene A, Olin B, Rush AJ. A patient-level meta-analysis of studies evaluating vagus nerve stimulation therapy for treatment-resistant depression. Med Devices (Auckl). 2013;6:17–35.
  74. Merrill CA, Jonsson MA, Minthon L, Ejnell H, Silander HC, Blennow K, et al. CsS H, Blennow K, Karlsson M, Nordlund A, Rolstad S, Warkentin S, Ben-Menachem E, Sjogren MJ. Vagus nerve stimulation in patients with Alzheimer’s disease: additional follow-up results of a pilot study through 1 year. J Clin Psychiatry. 2006;67(8):1171–8. doi:.
  75. Sjogren MJ, Hellstrom PT, Jonsson MA, Runnerstam M, Silander HC, Ben-Menachem E. Cognition-enhancing effect of vagus nerve stimulation in patients with Alzheimer’s disease: a pilot study. J Clin Psychiatry. 2002;63(11):972–80. doi:.