Severe behavioural and psychological symptoms in Alzheimer disease: a case report highlighting multimodal management and brexpiprazole use

A 69-year-old retired pastor with advanced Alzheimer dementia was admitted to a psychogeriatric unit for functional decline, severe agitation and psychosis. Collateral history described 12 months of increasing personal care resistance, with a 3-week deterioration marked by hallucination-associated toileting avoidance, overflow incontinence and care-related aggression. Home care was unviable despite substantial National Disability Insurance Scheme (NDIS) support. He was prescribed memantine and as-required risperidone for behavioural and psychological symptoms of dementia (BPSD), with comorbid affective disorders managed with mirtazapine and escitalopram. Clinical assessment was limited by psychosis and expressive aphasia. He mobilised independently but paced restlessly and exhibited severe care resistance, requiring coordinated intervention by multiple staff, including security. Investigations revealed no reversible medical contributors. Individualised non-pharmacological strategies were implemented with input from neuropsychology, the NDIS behaviour support and family. Interventions focussed on familiar sensory and religious cues, including Christian hymns, Bible verses, family photographs, familiar scents and his personal recliner chair. A structured behaviour management plan guided staff to approach the patient safely, identify early signs of agitation and intervene proactively to prevent escalation. Memantine was weaned and ceased during acute inpatient stay due to a temporal association with worsening hallucinations.1 Risperidone was rotated to quetiapine with minimal benefit. Escitalopram was discontinued due to lack of efficacy and concern regarding activating effects in severe agitation and polypharmacy.2 Sodium valproate was initiated and uptitrated. Benzodiazepine trials were ineffective, including sedation without clinical benefit. Agitation and care resistance persisted, preventing discharge to a residential aged care facility (RACF). Following consultation-liaison psychiatry review, antipsychotic rotation was recommended due to persistent psychotic symptoms, limited response to quetiapine and concern regarding sedation. Brexpiprazole was selected for its partial dopamine D2 agonism and serotonergic activity, with the aim of reducing psychosis while minimising sedation and extrapyramidal adverse effects. It was introduced gradually with tapering of quetiapine. Following transition, hallucination-related distress reduced, with improved cooperation during personal care. Hygiene could be completed with two staff without security involvement, and the patient began attempting to self-toilet. Although Rating Scale for Aggressive Behaviours in the Elderly (RAGE) scores showed minimal numerical change (Fig. 1), clinically meaningful improvements were observed in functional behaviours central to care delivery. Brexpiprazole was well tolerated, with no extrapyramidal symptoms, falls or sedation. On day 82, the patient was discharged to an RACF with a memory support unit. This case demonstrates a multimodal management approach, integrating individualised non-pharmacological strategies with sequential pharmacological interventions.3 Brexpiprazole, a serotonin–dopamine activity modulator, is the only Food and Drug Administration-approved treatment for agitation associated with Alzheimer dementia, supported by two 12-week randomised controlled trials.4, 5 In this case, brexpiprazole was associated with improved functional behaviours and appeared better tolerated than prior psychotropic trials. In Australia, brexpiprazole remains PBS-approved only for schizophrenia, with off-label use in BPSD limited by access and cost. This case highlights its potential effectiveness and tolerability in refractory psychosis in Alzheimer dementia. As with all antipsychotics use in dementia, brexpiprazole carries a class-associated increased mortality risk, necessitating careful patient selection, monitoring and shared-decision making. Further study is required to clarify its optimal positioning in BPSD management. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.