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 BMJ: first published as 10.1136/bmj-2021-069187 on 25 January 2022. Downloaded from http://www.bmj.com/ on 3 April 2022 at CHARLES STURT UNIVERSITY Subscription Services.
PRACTICE

1 Knowledge Translation Program, Li CLINICAL UPDATES

Ka Shing Knowledge Institute, St
Michael’s Hospital, Toronto, Canada

2 Division of Geriatric Medicine,

Managing neuropsychiatric symptoms in patients with dementia
Department of Medicine, University Jennifer A Watt, 1 , 2 Wade Thompson, 3 , 4 Roger Marple, Deborah Brown, 5 Barbara Liu2
of Toronto
What you need to know treat underlying causes is often limited. Little
3 Women’s College Research Institute,
evidence is available on interventions to lessen the
Toronto
• Non-medical interventions such as psychological severity and burden of symptoms. Guidelines from
4 Research Unit of General Practice, treatments and psychosocial and environmental the National Institute for Health and Care Excellence
University of Southern Denmark, modifications are recommended for people with (NICE) recommend offering non-medication
Odense, Denmark dementia who experience neuropsychiatric symptoms interventions as initial management for these
such as agitation, aggression, and depression
5 Lawrence S Bloomberg Faculty of symptoms.5 In many countries, Choosing Wisely
Nursing, University of Toronto • Evidence of low to moderate quality shows that campaigns emphasise non-medication interventions
multidisciplinary care and non-medication and recommend against use of antipsychotics as a
Correspondence to J A Watt
interventions are as effective, or more so, than
jennifer.watt@utoronto.ca first choice to treat these symptoms because of limited
medications (eg, antipsychotics) for reducing
Cite this as: BMJ 2022;376:e069187
neuropsychiatric symptoms
benefit and potential to cause harm, including
http://dx.doi.org/10.1136/bmj-2021-069187 premature death.6
Published: 25 January 2022
• Avoid prescribing medications in lieu of
antipsychotics (eg, antidepressants and In this article we discuss how healthcare
anticonvulsants) because they are associated with professionals can support people with dementia who
potential harms in people with dementia (eg, risk of are experiencing neuropsychiatric symptoms. We
fall or fracture) examine evidence for non-medication interventions,
• Develop person centred and measurable treatment and describe how to set patient centred goals, offer
goals and re-evaluate these at regular intervals a social prescription, and deprescribe antipsychotics.
• Support change at an organisational level by

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establishing an interprofessional team responsible Sources and selection criteria
for psychotropic medication stewardship, and agree We searched Medline, Embase, the Cochrane Library,
on criteria for appropriateness of psychotropic CINAHL, and PsycINFO for citations published in any
medication, educate care staff, inform and involve language from inception until 15 October 2020. Our
family and friend carers, and establish a process for search included subject headings and keywords for
regular review of medications “dementia,” “neuropsychiatric symptoms,” and
“randomized trials.” We also searched grey literature,
Neuropsychiatric symptoms such as depression and reviewed systematic reviews and guidelines, and
agitation are reported in 11% to 90% of community consulted with other clinical experts.
dwelling patients with dementia, as per a systematic
review published in 2015.1 These symptoms are How to assess patients with dementia who
associated with earlier admission to nursing homes have neuropsychiatric symptoms
and earlier functional decline in people with Patients may exhibit a range of behaviours that
dementia, and cause distress for carers.2 -4 suggest neuropsychiatric symptoms (table 1). These
Neuropsychiatric symptoms can be challenging to can be transient if the precipitant is acute, or may
treat in people with dementia. Access to persist for longer. Often carers notice changes in the
multidisciplinary care teams that can identify and patient’s behaviour and bring these to the attention
of care providers.

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PRACTICE

Table 1 | Neuropsychiatric symptoms in people with dementia7

Symptom Examples of how symptoms manifest in people with dementia
Agitation/aggression Hitting, kicking, restlessness, screaming
Depression/dysphoria Sadness, slowed movements or speech, early morning awakenings, mood congruent delusions
Delusions False beliefs that someone is trying to harm or steal from them
Hallucinations Hearing, feeling, or seeing people or things that are not real
Physical manifestations such as shortness of breath, separation anxiety, excessive worry,
Anxiety
excessive fear that something bad is going to happen
Elation/euphoria Excessive happiness
Apathy/indifference Less interest in participating in activities of daily living or other activities
Disinhibition Impulsiveness, saying or doing inappropriate things
Irritability/lability Impatience, easily made angry or sad
Motor disturbances Pacing, restlessness, performing the same activities repetitively, wandering
Night time behaviours Frequent night time awakenings, early morning awakenings, excessive daytime napping
Changes in appetite/eating Weight loss or weight gain, changes in food preferences

Evaluate the patient for signs of delirium, which include acute contributing to occurrence of these symptoms (table 2). Ask carers
changes in awareness of their environment, or changes in ability about consequences of symptoms to better understand if
to concentrate, and in cognition (eg, disorientation to time or inappropriate responses to symptoms are leading to further
place).7 8 If the suspicion for delirium is low, attempt to identify escalation (figure 1).9
factors in the patient’s environment or situation that may be

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Table 2 | Factors to consider when assessing neuropsychiatric symptoms of dementia
Factor Examples of contributors to neuropsychiatric symptoms of dementia
Protective Presence of a familiar carer
Being in a familiar environment
Carer knowledge of dementia
Availability of support for carers
Use of glasses and hearing aids
Creation of a tailored dementia care plan that alerts carers to important predisposing, precipitating,
and perpetuating factors for the person with dementia
Carer knowledge of person with dementia’s preferred non-medication interventions for reducing
neuropsychiatric symptoms
Predisposing Over- or under-stimulating environment
Vision or hearing impairment
Co-morbid psychiatric diagnoses
Worsening dementia severity
Carer burden or distress
Precipitating Pain
Hunger
Thirst
Medication changes
Feeling too hot or cold
Sleep disturbances
Perpetuating Poor communication strategies between carers and people with dementia
Inadequate identification and treatment of precipitating factor[s]
Inadequate implementation of the tailored dementia care plan
Lack of support for carers

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PRACTICE

Protected by copyright.

Fig 1 | Key steps in evaluating neuropsychiatric symptoms of dementia and developing a treatment plan

Use language that helps everyone understand contributing factors, in the kitchen and repetitively asking for snack foods. On further
the nature of the patient’s behaviour, and what happened (some questioning, a clinician discovers that these behaviours are
refer to these behaviours as “responsive behaviours”—that is, manifestations of anxiety because the person with dementia is
behaviours that are in response to external stimuli or unmet needs). worried that they cannot prepare their own food anymore; this
Try to avoid labelling behaviours as “agitation” or “aggression.” happens every day.
For example, instead of saying someone was “agitated,” a carer
could describe what happened: a person with dementia was pacing

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PRACTICE

Using person centred and specific language will help to develop inventory, Cohen-Mansfield agitation inventory) focus on specific
person centred and measurable goals (see “How to offer symptoms or behaviours (eg, biting, kicking) without providing
non-medication interventions" and table 3). Many scales used to needed context that enables meaningful goal setting.7 10
measure neuropsychiatric symptoms (eg, neuropsychiatric

Table 3 | Example of goal attainment scaling for a person with dementia experiencing anxiety
Outcome Person centred, clinically meaningful, and specific goals
Pacing in the kitchen and repetitively asking for snack foods between each meal (ie, every
Much worse than expected (−2)
morning, afternoon, and evening)
Pacing in the kitchen and repetitively asking for snack foods multiple times per day (eg, each
Somewhat worse than expected (−1)
morning and afternoon)
No change or expected (0) Pacing in the kitchen and repetitively asking for snack foods every day
Somewhat better than expected (+1) Pacing in the kitchen and repetitively asking for snack foods several days a week
Much better than expected (+2) No pacing in the kitchen; cessation of questions regarding snack foods

How to manage neuropsychiatric symptoms in people 28 483 patients, 41% of studies conducted in a clinic/community
with dementia setting) found that multidisciplinary care, occupational therapy,
and non-medication interventions (eg, animal therapy and exercise,
NICE guidelines support non-medication interventions including fig 2) resulted in clinically meaningful reductions in symptoms of
psychological therapies and psychosocial and environmental depression in people with dementia (without a major depressive
modifications as first line therapy in people with dementia who disorder).12 Medications alone were not more efficacious than usual
experience distressing neuropsychiatric symptoms.5 Medications care in both of these reviews.6 8 The level of confidence in review
are reserved only for certain situations associated with distress or findings was low to moderate for most treatment comparisons.
danger. Missing outcome data and a lack of participant blinding limit validity

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Multidisciplinary care and interventions such as massage and touch of findings (table 4).11 12 Studies included in these systematic reviews
therapy lead to clinically meaningful reductions in symptoms (ie, ranged from less than one week to two years in duration and were
the threshold above which clinicians, patients, and researchers conducted across different care settings (eg, community, nursing
perceive a change on an outcome scale) of agitation and aggression, home) in predominantly high income countries.11 12 The comparative
as per a systematic review (189 studies, 25 736 patients, 17.5% of cost effectiveness of efficacious interventions identified in these
studies conducted in a clinic/community setting) published in systematic reviews is unknown.
2019.11 Another systematic review published in 2021 (256 studies,

Fig 2 | Descriptions of efficacious non-medication interventions for reducing symptoms of depression in people with dementia

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PRACTICE

Table 4 | Efficacious interventions for reducing symptoms of depression, agitation, and aggression in people with dementia
Is this network
Studies in meta-analysis Is this meta-analysis
Treatment comparison Meta-analysis SMD Network meta-analysis meta-analysis treatment Level of confidence in
treatment comparison treatment effect
(v usual care) (95% CrI) SMD (95% CrI) effect clinically findings‡
(n*) clinically meaningful†?
meaningful†?
Efficacy of interventions in reducing depressive symptoms in people with dementia (who do not have a diagnosis of major depressive disorder)12
−0.94 −0.45
Animal therapy 1 (23) Yes No Low
(−1.76 to −0.16) (−1.24 to 0.39)
−0.67 −0.57
Cognitive stimulation 13 (805) Yes Yes Moderate
(−1.02 to −0.33) (−0.85 to −0.30)
Cognitive
−2.23
stimulation+cholinesterase - - - Yes Moderate
(−3.60 to −0.77)
inhibitor
−0.47 −0.27
Exercise 6 (581) Yes No Low
(−0.89 to −0.07) (−0.58 to 0.03)
Exercise+social
−2.40 −2.43
interaction+cognitive 1 (14) Yes Yes Moderate
(−3.41 to −1.43) (−3.73 to −1.05)
stimulation
Massage and touch −1.77 −1.77
3 (219) Yes Yes High
therapy (−2.42 to −1.12) (−2.41 to −1.15)
−0.48 −0.39
Multidisciplinary care 7 (838) Yes No Low
(−0.90 to −0.05) (−0.74 to −0.03)
−0.5 −0.51
Occupational therapy 5 (497) Yes Yes Moderate
(−1.02 to 0.02) (−0.92 to −0.08)
Psychotherapy+reminiscence
−0.99 −1.00
therapy+environmental 1 (51) Yes Yes Moderate
(−1.53 to −0.45) (−2.05 to 0.08)

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modification
−0.50 −0.45
Reminiscence therapy 14 (1163) Yes Yes Low
(−0.81 to −0.21) (−0.72 to −0.18)
Efficacy of interventions in reducing symptoms of agitation and aggression in people with dementia11
Massage and touch –0.9 –0.75
6 (385) Yes Yes Moderate
therapy (–1.28 to –0.51) (–1.12 to –0.38)
Music+massage and –1.71 –0.91
1 (34) Yes Yes Moderate
touch therapy (–2.36 to –1.05) (–1.75 to –0.07)
–0.44 –0.5
Multidisciplinary care 4 (552) Yes Yes Moderate
(–1 to 0.12) (–0.99 to –0.01)
–0.26 –0.29
Recreation therapy 8 (474) No No Moderate
(–0.64 to 0.12) (–0.57 to –0.01)
CrI=credible interval; SMD=standardised mean difference

* Sample sizes adjusted for clustering effect, where appropriate

† Level of confidence judged as per the CINeMA approach13
‡ Minimum clinically important difference defined as 2.0 points on the Cornell Scale for Depression in Dementia and 5.69 points on the Cohen Mansfield Agitation Inventory1112

How to offer non-medication interventions carers are attending programmes to support their own wellbeing)
(box 2).
Goal attainment scaling is a tool that can be person centred and
specific in measuring treatment response.14 In goal attainment Box 1: Free, plain language resources for patients and carers on treatment
scaling, people with dementia and carers describe a problem in choices for reducing neuropsychiatric symptoms in dementia (no
their own words, select a follow-up time for re-evaluation, define registration required)
one or more clinically meaningful treatment goals, and define
• Alzheimer’s Society “This is me” (a template completed by people
clinically meaningful improvement (table 3).14 Match them with
with dementia and carers explaining their personhood; available in
resources and decide on an appropriate follow-up time to ascertain
English and Welsh): https://www.alzheimers.org.uk/get-support/pub-
intervention effectiveness and measure progress.14 lications-factsheets/this-is-me
Check in with carers of people living with dementia to understand • Alzheimer’s Society “Caring for a person with dementia: a practical
how you can best support them in coping with their care giving role. guide”
Tailor interventions based on care setting, dementia severity, • Alzheimer’s Society “Carer information and support programme”
contributing factors, and the preferences and context of patient and • Choosing Wisely “Treating disruptive behaviour in people with
carers (table 2, box 1). Help people with dementia and carers to
dementia: antipsychotic medicines are usually not the best choice”
develop feasible treatment plans based on their local resources (eg, (available in English and Spanish): https://www.choosingwise-
concurrent availability of activities for people with dementia when ly.org/patient-resources/antipsychotic-drugs-for-people-with-demen-
tia/

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PRACTICE

• NICE decision aid “Antipsychotic medicines for treating agitation,

Identify community resources or connect patients with community
coordinators who have this knowledge. Share paper based and
aggression and distress in people living with dementia:”
https://www.nice.org.uk/guidance/ng97/resources online resources about locally available non-medication and
multidisciplinary care interventions for patients, to facilitate shared
• Alzheimer Society of Ontario’s Finding Your Way programme and
decision making.
Government of Ontario resource guide on living safely with dementia
(available in Italian, Spanish, Portuguese, English, French, Cantonese, What is the role of medications?
Mandarin, Punjabi, Tagalog, Arabic, Urdu, and Tamil): http://findingy-
ourwayontario.ca/ Reserve medications (eg, antipsychotics) for specific circumstances
• Dementia Australia guides on changed behaviours in dementia when symptoms are distressing to patients, or the patient poses an
(available in multiple languages including English, Hindi, Greek, imminent danger to themselves or others.5 9 17 18 Antipsychotics are
Korean, Dutch, German, and Polish): https://www.dementia.org.au/lan- associated with potential harms in people with dementia, including
guages an increased risk of stroke, falling, fracture, and death.17 19 -21
Use of antipsychotics in people with dementia is stabilising or
Box 2: Free additional resources for clinicians to support shared decision decreasing over time in Canada, the UK, and the US following
making (no registration required) targeted regulations and quality improvement initiatives. But use
of alternative psychotropic medications such as antidepressants
• Choosing Wisely toolkit on the appropriate use of antipsychotics: and anticonvulsants has been rising in people with dementia.22 -24
https://choosingwisely canada.org/perspective/antipsychotics- Observational studies have reported harms associated with
toolkit/
antipsychotic substitutes.25 -28 For example, trazodone (an
• Antipsychotic deprescribing resources: https://deprescribing.org/re- antidepressant) was associated with a similar risk of falling
sources/deprescribing-guidelines-algorithms/ compared with benzodiazepines or atypical antipsychotics in people
• Alzheimer’s Society “Optimising treatment and care for people with with dementia, but trazodone was associated with a decreased risk
behavioural and psychological symptoms of dementia:” of death compared with atypical antipsychotics.25 26 Anticonvulsants
https://www.alzheimers.org.uk/sites/default/files/2018-08/Optimis- were associated with an increased risk of death compared with
ing%20treatment%20and%20care%20-%20best%20prac- placebo in a subgroup of randomised trials included in a systematic
tice%20guide.pdf?downloadID=609
review enrolling people with dementia, where the mean population

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• Behavioural Supports Ontario resources to support people with age was at least 80 years.29
dementia experiencing neuropsychiatric symptoms and their carers:
https://www.behaviouralsupportsontario.ca/ How to deprescribe antipsychotic medications
• Dementia Support Australia “A Clinician’s Field Guide to Good At the time of prescribing, discuss treatment goals and establish a
Practice—Managing BPSD:” https://dementia.com.au/resources/li- timeline for review of symptoms. Define criteria for when
brary/behaviour/clinicians-guide-managing-bpsd.html medications should be discontinued and discuss alternative
interventions. A Cochrane review (10 trials, 632 participants) found
What is the role of social prescribing? low quality evidence that discontinuation of antipsychotics for
Social prescribing programmes link patients and carers with treating neuropsychiatric symptoms in older adults with dementia
community resources that support their social care needs.15 after at least three months has little or no effect on symptoms. A
Prescribed non-medication interventions in dementia can include subgroup analysis suggested potential worsening of
exercise, socialisation, and recreation programmes.11 12 15 A neuropsychiatric symptoms in those with more severe baseline
systematic review in 2017 identified limited evidence that social symptoms.30
prescribing improves patient wellbeing and did not identify any If you see a person with dementia who is taking psychotropic
studies specifically targeted at patients with dementia. More medication where the harms outweigh the benefits or where the
research is needed to support the implementation of social medication is not necessary or consistent with treatment
prescribing (box 3).15 16 preferences, consider deprescribing and discussion of alternative
non-medication interventions.5 However, do not initiate
Box 3: Questions for future research deprescribing in people with dementia and a concurrent chronic
• Do certain interventions work best in different stages of dementia, psychotic illness (eg, schizophrenia) without speaking with a
types of dementia, and settings (eg, community or nursing home)? clinician who has expertise in older patients’ mental health.31
• How can we best implement evidence informed policy that supports No validated tools are available to support psychotropic medication
equitable access to efficacious care interventions in our local deprescribing in patients with dementia.32 33 In people with
communities that are multidisciplinary and do not rely predominantly neuropsychiatric symptoms of dementia where symptoms have
on medication? stabilised or no response is seen to an adequate trial of
• How do we engage with communities to tailor social prescribing to antipsychotics, guidelines recommend slowly tapering
the needs of diverse groups of people with dementia and their carers? antipsychotics (eg, 25% to 50% dose reduction every one to two
• What measures of outcome, process, and balancing should we collect weeks until discontinued) in collaboration with the patient and
to ensure that initiatives aimed at improving care for people with carer, who can monitor for symptom recurrence.31 If
dementia experiencing neuropsychiatric symptoms are avoiding neuropsychiatric symptoms recur, discuss potential treatment
unintended harms? strategies:
• What are the best approaches to deprescribing medications and
de-implementing non-medication interventions for people with • Initiate non-medication interventions
dementia? Restart the antipsychotic with a goal to attempt deprescribing
•
again in three months. Make at least two attempts at
antipsychotic deprescribing, or

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PRACTICE

• Initiate an alternative psychotropic medication.11 31 expenses by AGE-WELL, the Canadian Consortium on Neurodegeneration in Aging, and the Alzheimer’s
Society of Canada; all other authors have no other interests to declare.
Support for providing non-medication interventions
Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/re-
Perceived lack of effectiveness, inadequate staffing or local resources sources-authors/forms-policies-and-checklists/declaration-competing-interests
to support people with dementia and their carers, lack of knowledge Contributorship statement: JAW (geriatrician and epidemiologist), WT (pharmacist and epidemiologist),
of the dangers associated with psychotropic medication use, and RM (patient partner), DB (nurse practitioner), and BL (geriatrician) contributed to the conception of
clinician attitudes towards neuropsychiatric symptom management this manuscript. JAW drafted the first version of the manuscript. All authors contributed to the critical
are barriers to implementing non-medication interventions.34 -36 revision of the manuscript.
Evidence based non-medication interventions may not be available Dissemination statement: We will disseminate our results to relevant knowledge user groups (people
in all communities. This can create an ethical dilemma for clinicians with dementia, carers, and clinicians).
who feel compelled to prescribe psychotropic medications.11 12 35
Provenance and peer review: commissioned, based on an idea from the authors; externally peer
Speak with patients and carers about these barriers and provide reviewed. This article is part of a series of Education articles based on recommendations from
resources to help them better advocate for their needs and international Choosing Wisely campaigns. Choosing Wisely had no input into the peer review process
preferences. or editorial decision. The BMJ thanks Wendy Levinson and Karen Born for valuable advice and supporting
the selection of topics.
Practices that support organisational level change include:
1 Borsje P, Wetzels RB, Lucassen PL, Pot AM, Koopmans RT. The course of neuropsychiatric
• Establishing an inter-professional team responsible for symptoms in community-dwelling patients with dementia: a systematic review. Int Psychogeriatr
psychotropic medication stewardship 2015;27:385-405. doi: 10.1017/S1041610214002282 pmid: 25403309
2 Fauth EB, Gibbons A. Which behavioral and psychological symptoms of dementia are the most
• Agreeing on psychotropic medication appropriateness criteria problematic? Variability by prevalence, intensity, distress ratings, and associations with caregiver
depressive symptoms. Int J Geriatr Psychiatry 2014;29:263-71.
• Educating care staff doi: 10.1002/gps.4002 pmid: 23846797
Informing and involving family and friend carers 3 Baharudin AD, Din NC, Subramaniam P, Razali R. The associations between
• behavioral-psychological symptoms of dementia (BPSD) and coping strategy, burden of care
• Establishing a regular medication review process, discontinuing and personality style among low-income caregivers of patients with dementia. BMC Public Health
potentially inappropriate medications, and implementing 2019;19(suppl 4):447. doi: 10.1186/s12889-019-6868-0 pmid: 31196141
4 Kaup BA, Loreck D, Gruber-Baldini AL, etal. Depression and its relationship to function and medical
non-medication strategies.6
status, by dementia status, in nursing home admissions. Am J Geriatr Psychiatry 2007;15:438-42.

Protected by copyright.
doi: 10.1097/JGP.0b013e31803c54f7 pmid: 17463194
Advocate for greater resources to improve timely and equitable 5 National Institute for Health and Care Excellence. Dementia: assessment, management and
access to multidisciplinary and social care in the community.37 support for people living with dementia and their carers, 2018. https://www.nice.org.uk/guid-
Consider implementing a systematic approach based on a treatment ance/ng97
manual (eg, DICE: describe, investigate, create, and evaluate) that 6 Choosing Wisely Canada. When psychosis isn’t the diagnosis: a toolkit for reducing inappropriate
supports people with dementia and carers in describing behaviours, use of antipsychotics in long term care. 2019. https://choosingwiselycanada.org/wp-content/up-
loads/2017/07/CWC_Antipsychotics_Toolkit_v1.0_2017-07-12.pdf
investigating causes of behaviours, creating treatment plans that
7 Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The
include potentially effective and feasible non-medication Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia.
interventions, and evaluating these treatment plans.38 39 Neurology 1994;44:2308-14. doi: 10.1212/WNL.44.12.2308 pmid: 7991117
8 Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association,
Education into practice 2013.
9 Dyer SM, Laver K, Pond CD, Cumming RG, Whitehead C, Crotty M. Cognitive Decline Partnership
• Think about the last time you spoke with a person living with dementia Centre. Clinical practice guidelines and principles of care for people with dementia. Australia.
and their carer about how neuropsychiatric symptoms associated 2016. https://pubmed.ncbi.nlm.nih.gov/27903038/
with dementia were affecting their lives. To what extent did you use 10 Cohen-Mansfield J, Marx MS, Rosenthal AS. A description of agitation in a nursing home. J Gerontol
person centred language (eg, describing examples of behaviours as 1989;44:M77-84. doi: 10.1093/geronj/44.3.M77 pmid: 2715584
opposed to using medical jargon) that would help patients and carers 11 Watt JA, Goodarzi Z, Veroniki AA, etal. Comparative efficacy of interventions for aggressive and
feel comfortable disclosing their concerns and describing their values agitated behaviors in dementia: a systematic review and network meta-analysis. Ann Intern Med
and goals? 2019;171:633-42. doi: 10.7326/M19-0993 pmid: 31610547
12 Watt JA, Goodarzi Z, Veroniki AA, etal. Comparative efficacy of interventions for reducing
• What would you do differently based on reading this article?
symptoms of depression in people with dementia: systematic review and network meta-analysis.
• How would you discuss non-medication interventions for BMJ 2021;372:n532. doi: 10.1136/bmj.n532 pmid: 33762262
neuropsychiatric symptoms of dementia? 13 Nikolakopoulou A, Higgins JPT, Papakonstantinou T, etal. CINeMA: An approach for assessing
confidence in the results of a network meta-analysis. PLoS Med 2020;17:e1003082.
doi: 10.1371/journal.pmed.1003082 pmid: 32243458
How patients were involved in the creation of this article 14 Jennings LA, Ramirez KD, Hays RD, Wenger NS, Reuben DB. Personalized goal attainment in
dementia care: measuring what persons with dementia and their caregivers want. J Am Geriatr
A person living with dementia who advocates for improving the lives of Soc 2018;66:2120-7. doi: 10.1111/jgs.15541 pmid: 30298901
people with dementia and their carers was involved in the conception, 15 Husk K, Blockley K, Lovell R, etal. What approaches to social prescribing work, for whom, and
writing, and revision of this article. In addition, a carer kindly reviewed in what circumstances? A realist review. Health Soc Care Community 2020;28:309-24.
this paper for The BMJ and emphasised the need to consider access, doi: 10.1111/hsc.12839 pmid: 31502314
costs, severity of disease, communicative abilities, and patients’ and 16 Bickerdike L, Booth A, Wilson PM, Farley K, Wright K. Social prescribing: less rhetoric and more
carers’ goals and preferences in tailoring the management. The reviewer reality. A systematic review of the evidence. BMJ Open 2017;7:e013384.
also suggested considering the patient’s contribution to goal setting. We doi: 10.1136/bmjopen-2016-013384 pmid: 28389486
have modified our example accordingly. 17 Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment
for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005;294:1934-43.
We gratefully acknowledge their inputs.
doi: 10.1001/jama.294.15.1934 pmid: 16234500
18 Gauthier S, Patterson C, Chertkow H, etal. Recommendations of the 4th Canadian consensus
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