Behavioural and psychological symptoms of dementia (BPSD) are common. Managing them can be very challenging. People dying at the end stages of dementia, may not exhibit behaviours that threaten or interfere with others. They may still exhibit apathy or withdrawal. 
Not all people living with dementia die of the effects of dementia. Many have other illnesses which are life limiting at an earlier stage of dementia, when behavioural symptoms are more frequent.
Look for other possible causes for the behaviour, such as:
- people with dementia have difficulty expressing their needs clearly and BPSD may be an expression of unmet need
- signs and symptoms of dementia, depression and pain often overlap and may have common causes 
- careful assessment and observation of the effect of treatment are essential to good management
- use of tools to assess and effectively manage pain and behaviours can improve the quality of life of people with advanced dementia. 
Possible non-dementia causes of behaviours of concern include:
- hunger, thirst and constipation
- muscle spasm or cramps from poor positioning
- inability to reposition self
- distress from surroundings (noise, light , too hot, too cold)
- caregiver interventions, and
- inappropriate medications.
Delirium is a potentially reversible cause of challenging behaviour. Differentiating between delirium and dementia can be difficult. The Department of Health and Ageing has produced Delirium Care Pathways to assist clinicians in acute and aged care to differentiate between delirium and dementia.
A consultation with a Geriatrician, Neurologist or Psychiatrist who specialises in dementia care will assist with behaviour management, care planning, provide reassurance for family and may resolve concerns about diagnosis.
- Medication for residents dying of dementia is problematic. There may be administration difficulties (difficulty in swallowing or medication refusal) and there is increased risk of adverse reaction or interaction between medications.
- There is limited research into the safety of medication for people with advanced dementia. 
- Medication use should be carefully considered. If required, a consultation with a psycho-geriatrician should be sought.
- The use of antipsychotic medication to manage behaviour has been linked to increased deaths from stroke and pneumonia. It offers only modest improvement in behaviour [5,6] but may be useful in selected residents.
- There is limited research in severe dementia. Questions remain as to cause of adverse events (disease process or medication) and the ethics of not treating severe and distressing symptoms like agitation and aggression. 
- A review of Valproate  has concluded that it is ineffective in managing agitation in dementia and carries unacceptable risk to patients.
- The evidence for the effectiveness of environmental interventions to manage behaviours in dementia is mixed. Supporting studies are often small and poorly reported. 
- Flexible, person centred care may limit the episodes of BPSD. Aromatherapy and calming music may reduce agitation. Bright light therapy may improve day time wakefulness and night time sleep for some residents. Maintaining a calm environment and avoiding changes to living arrangements and routines are good practice.
- A systematic review of non-pharmacological management strategies  for dementia found supporting evidence for interventions including:
- carer education
- preferred music
- bed baths
- person centred bathing, and
- muscle relaxation training.
Although reported benefits were small and response varied between residents, tailoring such interventions to the needs and preferences of individuals may increase their effectiveness.
Non-dementia causes of challenging behaviours
People with intellectual disability may exhibit difficult or challenging behaviours. For a discussion on the use of medication to manage challenging behaviours in intellectually disabled adults, see the free full text article below by Deb et al (2009).
People with personality disorders may also be admitted to RAC and can present a challenge for staff. There are guidelines for managing difficult personalities in the Palliative Care Network of Wisconsin Fast facts series on Borderline personality disorder in palliative care.