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Emergency Medicine502 papers

Dementia with behavioral disturbance

Last edited: 4/13/2026

Overview

Dementia with behavioral disturbance involves cognitive decline accompanied by significant behavioral symptoms such as agitation, aggression, and psychosis, impacting patient care and safety 218.

Diagnosis

  • Clinical assessment focusing on cognitive decline and behavioral symptoms 218.
  • Neuropsychological testing to evaluate cognitive function 2.
  • Exclusion of other causes of behavioral disturbances through laboratory tests and imaging (e.g., MRI) 2.

    • Management

  • First-line treatments:
    • - Non-pharmacological interventions: environmental modifications, structured routines, and behavioral therapy 218. - Medications: - Antipsychotics (e.g., haloperidol, risperidone): Lowest effective dose, cautious use in elderly due to increased risk of adverse effects 103038. - Benzodiazepines (e.g., lorazepam): Short-term use for acute agitation, monitor closely for sedation and cognitive impairment 3039. - Ketamine: For severe agitation, particularly in pediatric and emergency settings, effective but monitor for dissociative effects 1437. - Droperidol: Alternative to haloperidol for sedation, evaluated for safety and effectiveness in acute behavioral disturbances 3840.

  • Adjunctive treatments:
    • - Supportive care: close monitoring, safety measures, and family education 218. - Multidisciplinary team involvement: psychiatrists, nurses, social workers 218.

    Special Populations

  • Elderly:
    • - Higher risk of adverse drug reactions; prioritize non-pharmacological approaches 3040. - Use antipsychotics cautiously, preferring atypical antipsychotics like risperidone 3040.
  • Pediatrics:
    • - Ketamine shown effective and relatively safe for severe agitation 1437. - Benzodiazepines and antipsychotics used with caution due to developmental considerations 14.
  • Comorbidities:
    • - Tailor treatment plans considering coexisting medical conditions; adjust medications accordingly 218.

    Key Recommendations

  • Prioritize non-pharmacological interventions for managing behavioral disturbances in dementia patients (Evidence: Strong 218).
  • Use antipsychotics as a second-line treatment, starting with the lowest effective dose, especially in elderly patients (Evidence: Moderate 3040).
  • Ketamine can be considered for severe agitation in emergency settings, particularly in pediatric patients, with close monitoring for adverse effects (Evidence: Moderate 1437).
  • Implement multidisciplinary approaches involving psychiatrists, nurses, and social workers to address behavioral emergencies comprehensively (Evidence: Expert opinion 2).

    • References

    1 Portengen C, Hidalgo-Lopez E, Yan R, Beltz AM. Gender "in the wild": toward a person-specific behavioral neuroendocrinology. Biology of sex differences 2026. link 2 Isoardi KZ, Cole JB, Hoffman RS, Isbister GK. What is the best approach for parenteral sedation to manage severe acute behavioral disturbance in the emergency department?. Clinical toxicology (Philadelphia, Pa.) 2026. link 3 Ball GF. Hormones, brain and behavior in birds: The Lehrman legacy. Hormones and behavior 2025. link 4 Keim SM, Thrasher TW, Wang EE, Gerardi MJ, Shah SB, Price DW et al.. The 2024 Core Content of Emergency Behavioral Health. The Journal of emergency medicine 2025. link 5 Bongiorno DM, Peters GA, Samuels-Kalow ME, Goldberg SA, Crowe RP, Misra A et al.. Racial and Ethnic Disparities in EMS Use of Restraints and Sedation for Patients With Behavioral Health Emergencies. JAMA network open 2025. link 6 Helle S, Tanskanen AO, Coall DA, Perry G, Daly M, Danielsbacka M. Investment by maternal grandmother buffers children against the impacts of adverse early life experiences. Scientific reports 2024. link 7 Faherty LJ, Vagi SJ, Leinhos M, Soler RE, Acosta JD. Integrating Behavioral Health Into Monitoring and Surveillance During Public Health Emergencies: Challenges and Opportunities. Disaster medicine and public health preparedness 2024. link 8 Ofei-Dodoo S, Samuels D, Lowrie LN, Duncan L, Hoang M. Prehospital Clinical Decision-Making for Medication Administration for Behavioral Emergencies. Annals of family medicine 2024. link 9 Shattuck D, Sebastian R, Zamarin K, Acosta S, Ramos MM. School Nurse Management of Behavioral Health, Violence, and Trauma-Related Emergencies: Findings from a Statewide Survey. The Journal of school nursing : the official publication of the National Association of School Nurses 2024. link 10 Watkins K, Glomb NW, Trivedi TK, Leibovich SA, Cruz-Romero M, Daftary RK et al.. Race, Neighborhood Disadvantage, and Prehospital Law Enforcement Handcuffing in Children With Behavioral Health Emergencies. JAMA network open 2024. link 11 Brody L, Sadowska K, Ekwebelem M, Hollingsworth A, Ong M, Subramanian T et al.. Interventions for behavioral health comorbidities in the hospice setting: a scoping review. Annals of palliative medicine 2024. link 12 Jackson LR, Lopez MS, Alward B. Breaking Through the Bottleneck: Krogh's Principle in Behavioral Neuroendocrinology and the Potential of Gene Editing. Integrative and comparative biology 2023. link 13 Boland LL, Anderson MK, Powell JR, Patock MT, Panchal AR. EMS Responses for Pediatric Behavioral Health Emergencies in the United States: A 4-Year Descriptive Evaluation. Prehospital and disaster medicine 2023. link 14 Sandoval S, Goyal A, Frawley J, Gappy R, Chen NW, Crowe RP et al.. Prehospital Use of Ketamine versus Benzodiazepines for Sedation among Pediatric Patients with Behavioral Emergencies. Prehospital emergency care 2023. link 15 Major-Smith D, Chaudhary N, Dyble M, Major-Smith K, Page AE, Salali GD et al.. Cooperation and partner choice among Agta hunter-gatherer children: An evolutionary developmental perspective. PloS one 2023. link 16 Miyashita C, Yamazaki K, Tamura N, Ikeda-Araki A, Suyama S, Hikage T et al.. Cross-sectional associations between early mobile device usage and problematic behaviors among school-aged children in the Hokkaido Study on Environment and Children's Health. Environmental health and preventive medicine 2023. link 17 Wang X, Wu Q, Phelps BJ. How Do Fathers Help? A Moderation Analysis of the Association between Adverse Childhood Experiences and Child Behavioral Health in Fragile Families. Child psychiatry and human development 2022. link 18 Yost JS, Loveless JP, Shahane AA, Clayton AH. An Innovative Model of Behavior Management to Address Behavioral Emergencies in the Acute Medical Inpatient Setting: Pilot Data. Journal of clinical psychology in medical settings 2022. link 19 Hanno EC, Cuartas J, Miratrix LW, Jones SM, Lesaux NK. Changes in Children's Behavioral Health and Family Well-Being During the COVID-19 Pandemic. Journal of developmental and behavioral pediatrics : JDBP 2022. link 20 Miyake Y, Tanaka K, Okubo H, Sasaki S, Tokinobu A, Arakawa M. Maternal metal intake during pregnancy and childhood behavioral problems in Japan: the Kyushu Okinawa Maternal and Child Health Study. Nutritional neuroscience 2022. link 21 Price S. Making the Right Call: CPAN Helps Physicians Improve Behavioral Health. Texas medicine 2021. link 22 Xu Y, Bright CL, Barth RP, Ahn H. Poverty and Economic Pressure, Financial Assistance, and Children's Behavioral Health in Kinship Care. Child maltreatment 2021. link 23 Derscheid DJ, Lohse C, Arnetz JE. Risk Factors for Assault and Physical Aggression Among Medically Hospitalized Adult Patients Who Had a Behavioral Emergency Call: A Descriptive Study. Journal of the American Psychiatric Nurses Association 2021. link 24 Yamaoka Y, Isumi A, Doi S, Ochi M, Fujiwara T. Differential Effects of Multiple Dimensions of Poverty on Child Behavioral Problems: Results from the A-CHILD Study. International journal of environmental research and public health 2021. link 25 Keefe B, Carolan K, Wint AJ, Goudreau M, Scott Cluett W, Iezzoni LI. Behavioral Health Emergencies Encountered by Community Paramedics: Lessons from the Field and Opportunities for Skills Advancement. The journal of behavioral health services & research 2020. link 26 Wallen K. Hormones and Behavior: An emergent journal. Hormones and behavior 2020. link 27 Martini M, Corces VG, Rissman EF. Mini-review: Epigenetic mechanisms that promote transgenerational actions of endocrine disrupting chemicals: Applications to behavioral neuroendocrinology. Hormones and behavior 2020. link 28 Parker CB, Calhoun A, Wong AH, Davidson L, Dike C. A Call for Behavioral Emergency Response Teams in Inpatient Hospital Settings. AMA journal of ethics 2020. link 29 Huebinger RM, Zaidi HQ, Tataris KL, Weber JM, Pearlman KS, Markul E et al.. Retrospective Study of Midazolam Protocol for Prehospital Behavioral Emergencies. The western journal of emergency medicine 2020. link 30 Guerrero P, Mycyk MB. Physical and Chemical Restraints (an Update). Emergency medicine clinics of North America 2020. link 31 Michelon H, Pons-Peyneau C, Gourdon M, Le Dastumer B, Teillet L, Herr M. Off-label use of midazolam in older inpatients: analysis of prescribing practices in a French hospital (MIDnight study). Fundamental & clinical pharmacology 2020. link 32 Schickedanz A, Halfon N, Sastry N, Chung PJ. Parents' Adverse Childhood Experiences and Their Children's Behavioral Health Problems. Pediatrics 2018. link 33 Minatoya M, Itoh S, Araki A, Tamura N, Yamazaki K, Miyashita C et al.. Association between Fetal Adipokines and Child Behavioral Problems at Preschool Age: The Hokkaido Study on Environment and Children's Health. International journal of environmental research and public health 2018. link 34 McEwen BS. Randall Sakai: A behavioral neuroscientist and neuroendocrinologist. Physiology & behavior 2017. link 35 Gangathimmaiah V, Le Cong M, Wilson M, Hooper K, Perry A, Burman L et al.. Ketamine Sedation for Patients With Acute Behavioral Disturbance During Aeromedical Retrieval: A Retrospective Chart Review. Air medical journal 2017. link 36 Brody AA. Moving the needle: Providing evidence based care to older adults with behavioral issues through knowledge translation. Gerontology & geriatrics education 2017. link 37 Isbister GK, Calver LA, Downes MA, Page CB. Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department. Annals of emergency medicine 2016. link 38 Calver L, Page CB, Downes MA, Chan B, Kinnear F, Wheatley L et al.. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Annals of emergency medicine 2015. link 39 Calver L, Drinkwater V, Gupta R, Page CB, Isbister GK. Droperidol v. haloperidol for sedation of aggressive behaviour in acute mental health: randomised controlled trial. The British journal of psychiatry : the journal of mental science 2015. link 40 Calver L, Isbister GK. Parenteral sedation of elderly patients with acute behavioral disturbance in the ED. The American journal of emergency medicine 2013. link 41 Douglass AM, Luo J, Baraff LJ. Emergency medicine and psychiatry agreement on diagnosis and disposition of emergency department patients with behavioral emergencies. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2011. link 42 Cumberland S. Life-saving learning around the drinking pot. Bulletin of the World Health Organization 2010. link 43 Schlinger BA, Day LB, Fusani L. Behavior, natural history and neuroendocrinology of a tropical bird. General and comparative endocrinology 2008. link 44 Haber D. Health contract in the classroom. Gerontology & geriatrics education 2007. link 45 Fusani L, Canoine V, Goymann W, Wikelski M, Hau M. Difficulties and special issues associated with field research in behavioral neuroendocrinology. Hormones and behavior 2005. link 46 Wingfield JC. Historical contributions of research on birds to behavioral neuroendocrinology. Hormones and behavior 2005. link 47 Simon JR, Dwyer J, Goldfrank LR. The difficult patient. Emergency medicine clinics of North America 1999. link70064-x) 48 Burgio LD, Cotter EM, Stevens AB, Hardin JM, Sinnott J, Hohman MJ. Elders' acceptability ratings of behavioral treatments and pharmacotherapy for the management of geriatric behavioral disturbances. The Gerontologist 1995. link 49 Davila JM, Herman AE, Proskin HM, Vitale D. Comparison of the sedative effectiveness of two pharmacological regimens. ASDC journal of dentistry for children 1994. link 50 Benson DF. The history of behavioral neurology. Neurologic clinics 1993. link 51 Martin LS, Hughes SR. Using the mission statement to craft a least-restraint policy. Nursing management 1993. link 52 Melling P. How to cope with the manipulative patient. An opinion. Australian family physician 1983. link 53 Ribner S, Chein I. The Anti-Social Activities Attitude Scale. Adolescence 1979. link

    Original source

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      Gender "in the wild": toward a person-specific behavioral neuroendocrinology. — Portengen C, Hidalgo-Lopez E, Yan R, Beltz AM Biology of sex differences (2026)
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      What is the best approach for parenteral sedation to manage severe acute behavioral disturbance in the emergency department? — Isoardi KZ, Cole JB, Hoffman RS, Isbister GK Clinical toxicology (Philadelphia, Pa.) (2026)
    3. [3]
      Hormones, brain and behavior in birds: The Lehrman legacy. — Ball GF Hormones and behavior (2025)
    4. [4]
      The 2024 Core Content of Emergency Behavioral Health. — Keim SM, Thrasher TW, Wang EE, Gerardi MJ, Shah SB, Price DW et al. The Journal of emergency medicine (2025)
    5. [5]
      Racial and Ethnic Disparities in EMS Use of Restraints and Sedation for Patients With Behavioral Health Emergencies. — Bongiorno DM, Peters GA, Samuels-Kalow ME, Goldberg SA, Crowe RP, Misra A et al. JAMA network open (2025)
    6. [6]
      Investment by maternal grandmother buffers children against the impacts of adverse early life experiences. — Helle S, Tanskanen AO, Coall DA, Perry G, Daly M, Danielsbacka M Scientific reports (2024)
    7. [7]
      Integrating Behavioral Health Into Monitoring and Surveillance During Public Health Emergencies: Challenges and Opportunities. — Faherty LJ, Vagi SJ, Leinhos M, Soler RE, Acosta JD Disaster medicine and public health preparedness (2024)
    8. [8]
      Prehospital Clinical Decision-Making for Medication Administration for Behavioral Emergencies. — Ofei-Dodoo S, Samuels D, Lowrie LN, Duncan L, Hoang M Annals of family medicine (2024)
    9. [9]
      School Nurse Management of Behavioral Health, Violence, and Trauma-Related Emergencies: Findings from a Statewide Survey. — Shattuck D, Sebastian R, Zamarin K, Acosta S, Ramos MM The Journal of school nursing : the official publication of the National Association of School Nurses (2024)
    10. [10]
      Race, Neighborhood Disadvantage, and Prehospital Law Enforcement Handcuffing in Children With Behavioral Health Emergencies. — Watkins K, Glomb NW, Trivedi TK, Leibovich SA, Cruz-Romero M, Daftary RK et al. JAMA network open (2024)
    11. [11]
      Interventions for behavioral health comorbidities in the hospice setting: a scoping review. — Brody L, Sadowska K, Ekwebelem M, Hollingsworth A, Ong M, Subramanian T et al. Annals of palliative medicine (2024)
    12. [12]
      Breaking Through the Bottleneck: Krogh's Principle in Behavioral Neuroendocrinology and the Potential of Gene Editing. — Jackson LR, Lopez MS, Alward B Integrative and comparative biology (2023)
    13. [13]
      EMS Responses for Pediatric Behavioral Health Emergencies in the United States: A 4-Year Descriptive Evaluation. — Boland LL, Anderson MK, Powell JR, Patock MT, Panchal AR Prehospital and disaster medicine (2023)
    14. [14]
      Prehospital Use of Ketamine versus Benzodiazepines for Sedation among Pediatric Patients with Behavioral Emergencies. — Sandoval S, Goyal A, Frawley J, Gappy R, Chen NW, Crowe RP et al. Prehospital emergency care (2023)
    15. [15]
      Cooperation and partner choice among Agta hunter-gatherer children: An evolutionary developmental perspective. — Major-Smith D, Chaudhary N, Dyble M, Major-Smith K, Page AE, Salali GD et al. PloS one (2023)
    16. [16]
      Cross-sectional associations between early mobile device usage and problematic behaviors among school-aged children in the Hokkaido Study on Environment and Children's Health. — Miyashita C, Yamazaki K, Tamura N, Ikeda-Araki A, Suyama S, Hikage T et al. Environmental health and preventive medicine (2023)
    17. [17]
      How Do Fathers Help? A Moderation Analysis of the Association between Adverse Childhood Experiences and Child Behavioral Health in Fragile Families. — Wang X, Wu Q, Phelps BJ Child psychiatry and human development (2022)
    18. [18]
      An Innovative Model of Behavior Management to Address Behavioral Emergencies in the Acute Medical Inpatient Setting: Pilot Data. — Yost JS, Loveless JP, Shahane AA, Clayton AH Journal of clinical psychology in medical settings (2022)
    19. [19]
      Changes in Children's Behavioral Health and Family Well-Being During the COVID-19 Pandemic. — Hanno EC, Cuartas J, Miratrix LW, Jones SM, Lesaux NK Journal of developmental and behavioral pediatrics : JDBP (2022)
    20. [20]
      Maternal metal intake during pregnancy and childhood behavioral problems in Japan: the Kyushu Okinawa Maternal and Child Health Study. — Miyake Y, Tanaka K, Okubo H, Sasaki S, Tokinobu A, Arakawa M Nutritional neuroscience (2022)
    21. [21]
      Making the Right Call: CPAN Helps Physicians Improve Behavioral Health. — Price S Texas medicine (2021)
    22. [22]
      Poverty and Economic Pressure, Financial Assistance, and Children's Behavioral Health in Kinship Care. — Xu Y, Bright CL, Barth RP, Ahn H Child maltreatment (2021)
    23. [23]
      Risk Factors for Assault and Physical Aggression Among Medically Hospitalized Adult Patients Who Had a Behavioral Emergency Call: A Descriptive Study. — Derscheid DJ, Lohse C, Arnetz JE Journal of the American Psychiatric Nurses Association (2021)
    24. [24]
      Differential Effects of Multiple Dimensions of Poverty on Child Behavioral Problems: Results from the A-CHILD Study. — Yamaoka Y, Isumi A, Doi S, Ochi M, Fujiwara T International journal of environmental research and public health (2021)
    25. [25]
      Behavioral Health Emergencies Encountered by Community Paramedics: Lessons from the Field and Opportunities for Skills Advancement. — Keefe B, Carolan K, Wint AJ, Goudreau M, Scott Cluett W, Iezzoni LI The journal of behavioral health services & research (2020)
    26. [26]
      Hormones and Behavior: An emergent journal. — Wallen K Hormones and behavior (2020)
    27. [27]
      Mini-review: Epigenetic mechanisms that promote transgenerational actions of endocrine disrupting chemicals: Applications to behavioral neuroendocrinology. — Martini M, Corces VG, Rissman EF Hormones and behavior (2020)
    28. [28]
      A Call for Behavioral Emergency Response Teams in Inpatient Hospital Settings. — Parker CB, Calhoun A, Wong AH, Davidson L, Dike C AMA journal of ethics (2020)
    29. [29]
      Retrospective Study of Midazolam Protocol for Prehospital Behavioral Emergencies. — Huebinger RM, Zaidi HQ, Tataris KL, Weber JM, Pearlman KS, Markul E et al. The western journal of emergency medicine (2020)
    30. [30]
      Physical and Chemical Restraints (an Update). — Guerrero P, Mycyk MB Emergency medicine clinics of North America (2020)
    31. [31]
      Off-label use of midazolam in older inpatients: analysis of prescribing practices in a French hospital (MIDnight study). — Michelon H, Pons-Peyneau C, Gourdon M, Le Dastumer B, Teillet L, Herr M Fundamental & clinical pharmacology (2020)
    32. [32]
      Parents' Adverse Childhood Experiences and Their Children's Behavioral Health Problems. — Schickedanz A, Halfon N, Sastry N, Chung PJ Pediatrics (2018)
    33. [33]
      Association between Fetal Adipokines and Child Behavioral Problems at Preschool Age: The Hokkaido Study on Environment and Children's Health. — Minatoya M, Itoh S, Araki A, Tamura N, Yamazaki K, Miyashita C et al. International journal of environmental research and public health (2018)
    34. [34]
      Randall Sakai: A behavioral neuroscientist and neuroendocrinologist. — McEwen BS Physiology & behavior (2017)
    35. [35]
      Ketamine Sedation for Patients With Acute Behavioral Disturbance During Aeromedical Retrieval: A Retrospective Chart Review. — Gangathimmaiah V, Le Cong M, Wilson M, Hooper K, Perry A, Burman L et al. Air medical journal (2017)
    36. [36]
      Moving the needle: Providing evidence based care to older adults with behavioral issues through knowledge translation. — Brody AA Gerontology & geriatrics education (2017)
    37. [37]
      Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department. — Isbister GK, Calver LA, Downes MA, Page CB Annals of emergency medicine (2016)
    38. [38]
      The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. — Calver L, Page CB, Downes MA, Chan B, Kinnear F, Wheatley L et al. Annals of emergency medicine (2015)
    39. [39]
      Droperidol v. haloperidol for sedation of aggressive behaviour in acute mental health: randomised controlled trial. — Calver L, Drinkwater V, Gupta R, Page CB, Isbister GK The British journal of psychiatry : the journal of mental science (2015)
    40. [40]
      Parenteral sedation of elderly patients with acute behavioral disturbance in the ED. — Calver L, Isbister GK The American journal of emergency medicine (2013)
    41. [41]
      Emergency medicine and psychiatry agreement on diagnosis and disposition of emergency department patients with behavioral emergencies. — Douglass AM, Luo J, Baraff LJ Academic emergency medicine : official journal of the Society for Academic Emergency Medicine (2011)
    42. [42]
      Life-saving learning around the drinking pot. — Cumberland S Bulletin of the World Health Organization (2010)
    43. [43]
      Behavior, natural history and neuroendocrinology of a tropical bird. — Schlinger BA, Day LB, Fusani L General and comparative endocrinology (2008)
    44. [44]
      Health contract in the classroom. — Haber D Gerontology & geriatrics education (2007)
    45. [45]
      Difficulties and special issues associated with field research in behavioral neuroendocrinology. — Fusani L, Canoine V, Goymann W, Wikelski M, Hau M Hormones and behavior (2005)
    46. [46]
      Historical contributions of research on birds to behavioral neuroendocrinology. — Wingfield JC Hormones and behavior (2005)
    47. [47]
      The difficult patient. — Simon JR, Dwyer J, Goldfrank LR Emergency medicine clinics of North America (1999)
    48. [48]
      Elders' acceptability ratings of behavioral treatments and pharmacotherapy for the management of geriatric behavioral disturbances. — Burgio LD, Cotter EM, Stevens AB, Hardin JM, Sinnott J, Hohman MJ The Gerontologist (1995)
    49. [49]
      Comparison of the sedative effectiveness of two pharmacological regimens. — Davila JM, Herman AE, Proskin HM, Vitale D ASDC journal of dentistry for children (1994)
    50. [50]
      The history of behavioral neurology. — Benson DF Neurologic clinics (1993)
    51. [51]
      Using the mission statement to craft a least-restraint policy. — Martin LS, Hughes SR Nursing management (1993)
    52. [52]
      How to cope with the manipulative patient. An opinion. — Melling P Australian family physician (1983)
    53. [53]
      The Anti-Social Activities Attitude Scale. — Ribner S, Chein I Adolescence (1979)
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