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Kales — BPSD and DICE (Harvard CME 2025)

Kales, H.C. "What are we going to do with Grandma Tina?" UC Davis Department of Psychiatry, Harvard CME Dementia Course, May 9, 2025. Background framework published as Kales, Gitlin & Lyketsos, BMJ 2015.

Key findings used in wiki

Behavioral and psychological symptoms are near-universal in dementia

  • Non-cognitive behavioral and psychological symptoms of dementia (BPSD) are present in more than 98% of people with dementia over the course of the disease.
  • They occur at any stage, with every dementia subtype, and often dominate the disease course in practice even when cognition is the named problem.
  • Common BPSD include depression, anxiety, apathy, psychosis, agitation, and aggression — and often more than one at once.
  • BPSD are associated with poor outcomes for both the person with dementia and the family caregiver.
  • The family caregiver role is central — most BPSD events happen at home, are managed at home, and reshape caregiving demand in the process.

The core problems in real-world BPSD care

  • Big problem #1 — resource access: Specialists are few and concentrated in academic centers. Primary care physicians have too little dementia-specific training. Dementia crosses legal, financial, functional, and social spheres, and caregivers often cannot find or access the right help precisely when they need it.
  • Big problem #2 — lack of personalization and precision: Current dementia care is rarely tailored to the specific person, subtype, stage, or family context.
  • Big problem #3 — workforce: Most frontline dementia-care workers have little specialized training, which compounds risk when behavior escalates.

The DICE approach

  • DICE is the canonical non-pharmacological framework for BPSD: Describe the behavior in context, Investigate possible contributors (medical, environmental, caregiver, person-specific), Create a plan that addresses the most likely contributor first, and Evaluate whether it worked and what to try next.
  • DICE treats BPSD as a product of the person, caregiver, and environment together, not a symptom to medicate in isolation.
  • Medications have a role but should typically follow non-pharmacological approaches, and specific agents (e.g., brexpiprazole) are used within a broader plan.

Why it matters for the wiki

  • Grounds the behavioral-changes passage on conditions/dementia.md: aggression, paranoia, repetition, and personality shifts are disease symptoms (BPSD) that are near-universal and rarely one-off, so caregivers benefit from a framework, not just coping advice.
  • Supports the caregiver-facing point on guides/crisis.md and guides/daily-care.md that behavior change has a reason, and that the first step is to describe and investigate — environment, pain, medication, infection, routine — before reaching for a prescription.