Like beauty and contact lenses, the meaning of dementia behavioral changes is in the eyes of the beholder

Dementia, calledMajor Neurocognitive Disorder in the DSM-5, is a syndrome associated with progressive and irreversible decline of brain functioning, leading inevitably to dependent on others to perform activities of daily living. Dementia can be the result of a variety of diseases, but 60–70% of the cases are caused by Alzheimer’s disease (AD). Recent epidemiological estimations suggest that the number of people living with dementia worldwide will increase from about 55 million today to approximately 78 million in 2030 and 139 million in 2050 (World Health Organization, 2022). Although the main clinical manifestation of dementia is a significant decrease in cognitive functioning (thinking, remembering, and reasoning), most individuals with the diagnosis also display noncognitive symptoms at some stage of the disorder. These are commonly referred to as behavioral and psychological symptoms of dementia (BPSD) and may be classified into four clusters: psychosis (delusions and hallucinations), affective syndrome (anxiety and depression), psychomotor syndrome (agitation, aberrant motor behavior, irritability), and mania (euphoria, disinhibition, apathy). A recent systematic review based on 30 cross-sectional studies showed that the prevalence of BPSD in the community ranged from 4% (for mania disturbances) to 56% (for anxiety), depending on the type and severity of dementia and the behavior examined (Kwon and Lee, 2021). Higher rates were reported by other reviews, including longitudinal studies and those conducted in acute care and long-term institutions. Overall, it is estimated that up to 90% of people living with dementia display at least one type of BPSD during the course of their illness. Such extremely high prevalence rates are worrisome especially given the harmful consequences of BPSD. These include decreased quality of life and quality of treatment and increased distress and health deterioration of both people living with dementia and their caregivers. Other negative effects of BPSD include increased stigma, frequent hospitalization, and early institutionalization. Clarifying the causes and the meaning of BPSD is, therefore, crucial for preventing, managing, and reducing their economic and emotional costs (Burley et al., 2020). Recent studies have started moving away from an understanding of BPSD as a series of pathophysiological changes in the brain to the recognition that it involves a complex interaction between biological, psychological, and social factors (Werner et al., 2022). Today, threemainmodels are used to explain BPSD: (a) the unmet needs model (also called the need-driven, dementia-compromised behavior model) conceptualizes BPSD as the manifestation of distress provoked by physical or psychological needs (such as pain or loneliness) that the person with dementia is unable to communicate and satisfy, often as a result of caregivers’ inability to understand them (Cohen-Mansfield, 2000); (b) the behavioral/ learning model postulates that BPSD is the result of a conditioning process emerging in response to environmental triggers, especially caregivers reinforcing disruptive behavior This model led to the development of the Antecedent-Behavior-Consequence (A-B-C) approach for the management of BPSD which seeks to identify and reduce the antecedents by providing adequate responses; (c) the environmental vulnerability/reduced stress-threshold model explains the manifestation of BPSD as a reaction to discrepancies between the needs and capacities of the person with dementia and the overor understimulating environment (Cohen-Mansfield, 2000). These psychosocial models for the understanding and treatment of BPSD are not mutually exclusive and are all based on a person-centered approach. Dementia person-centered care, initiated by Kitwood (1997), proposes to expand the reductionist biomedical view of dementia through a holistic perspective aimed at improving the quality of life and care of people with dementia based on their remaining strengths, individual needs, values, and preferences. Yet, the well-being of people with dementia is closely tied to that of their caregivers, especially when dealing with the onset of BPSD, which is closely related to caregivers’ distress and burden. Recently, dementia person-centered care has been expanded into a “relationship-centered” approach that includes the views and preferences of the person with dementia and the caregiver, their relationship, and communication patterns (Mohr et al., 2021). The work by Burley et al. (2022) is International Psychogeriatrics (2023), 35:2, 59–61 © International Psychogeriatric Association 2022