What are the strategies for identifying and managing agitation in patients with advanced dementia?

From the Guidelines

Identifying and managing agitation in advanced dementia requires a systematic approach beginning with non-pharmacological interventions before considering medications, with a focus on minimizing harm and improving quality of life, as recommended by the most recent guidelines 1. When managing agitation in patients with advanced dementia, it is essential to first identify potential triggers of agitation, such as pain, infection, constipation, hunger, or environmental factors like noise or unfamiliar surroundings.

• Use validated assessment tools like the Cohen-Mansfield Agitation Inventory or Neuropsychiatric Inventory to quantify symptoms.
• Non-pharmacological approaches should be tried first, including:
  • Maintaining a consistent routine
  • Providing familiar objects
  • Using music therapy
  • Engaging in meaningful activities
  • Ensuring adequate lighting
  • Training caregivers in communication techniques
  • Simulated presence therapy (SPT) using audio or video recordings prepared by family members or surrogates
  • Massage therapy, animal-assisted interventions, personally tailored interventions, and even pet robot interventions, as suggested by recent guidelines 1 If these approaches fail, pharmacological management may be necessary, with SSRIs like citalopram (10-20mg daily) or sertraline (25-50mg daily) considered first-line treatments for agitation due to their relatively favorable side effect profile and effectiveness in reducing overall neuropsychiatric symptoms, agitation, and depression in individuals with vascular cognitive impairment (VCI) 1.
• Antipsychotics such as risperidone, quetiapine, or olanzapine may be used, but with caution due to the increased risk of death, probably from cardiac toxicities, and should be used at the lowest effective dose for the shortest duration, as recommended by the American Psychiatric Association practice guideline 1. Regular medication reviews every 4-6 weeks are essential to assess continued need and monitor for side effects, with the goal of tapering or discontinuing medications when possible, as stated in the guideline 1.

From the Research

Strategies for Identifying and Managing Agitation in Patients with Advanced Dementia

• Non-pharmacological interventions are being increasingly implemented to manage agitation in patients with dementia, as medications often have adverse reactions and limited effectiveness 2
• Effective non-pharmacological interventions for managing agitation in patients with dementia include:
  • Massage therapy
  • Animal-assisted intervention
  • Personally tailored intervention
  • Behavioural therapy
  • Balancing arousal states
  • Therapeutic touch
  • Multi-sensory stimulation
  • Person-centred bathing
  • Supervised person-centred care
  • Communication skills
  • Modified dementia care mapping (DCM) with implementing plans
  • Activities
  • Music therapy
  • Sensory intervention 2, 3, 4, 5
• Environmental modification, education of caregivers, and therapeutic activity programs are also nonpharmacologic approaches that can effectively reduce some signs and symptoms of agitation 3
• A comprehensive biopsychosocial assessment and treatment plan is likely the most effective way to manage agitation in patients with dementia 6
• The following medications may be considered as alternatives to antipsychotics for the treatment of agitation in patients with dementia:
  • Cholinesterase inhibitors
  • Serotonin-specific reuptake inhibitor antidepressants
  • Antiepileptics
  • Lithium
  • Anxiolytics
  • Analgesics
  • Beta-adrenoceptor antagonists
  • Cannabinoid receptor agonists
  • Hormonal agents 6

Assessment and Treatment Planning

• A careful assessment is necessary to rule out potentially reversible factors contributing to agitation in patients with dementia 6
• The assessment should consider physical, environmental, social, and psychiatric factors that may be contributing to the agitation 3
• The treatment plan should be individualized and tailored to the specific needs of the patient 2, 6, 4, 5

Settings and Caregivers

• Non-pharmacological interventions can be implemented by nurses and other caregivers in residential aged care facilities and other settings 4, 5
• Family carers can also be trained in behavioural or cognitive interventions to help manage agitation in patients with dementia, although the evidence for this is limited 5
• Care home culture can be changed through staff training and permanent implementation of evidence-based treatments to reduce agitation in care-home dementia residents 5