What is the first line to help calm down a patient with agitation and dementia not on medication?

First-Line Management for Agitation in Dementia

Non-pharmacological interventions should always be used as first-line treatment for agitation in patients with dementia before considering any medications. 1, 2

Non-Pharmacological Approaches

Immediate Calming Strategies

1. Apply the "Three R's" technique:

   • Repeat instructions or answers as needed
   • Reassure the patient
   • Redirect attention to divert from problematic situations 2

2. Environmental modifications:

   • Reduce excessive stimulation (noise, clutter, glare)
   • Ensure adequate lighting to reduce confusion
   • Create a calm, familiar environment 2, 1

3. Therapeutic approaches (in order of effectiveness):

   • Music therapy (most effective)
   • Aromatherapy and massage
   • Physical exercise 3

Structured Interventions

• Establish predictable daily routines for meals, exercise, and bedtime
• Use simple, clear language when communicating
• Break complex tasks into simple steps
• Allow patients to keep personal possessions and wear their own clothing
• Provide orientation tools (calendars, clocks, labels) 2, 1

When to Consider Medications

Only consider pharmacological interventions when:

1. Non-pharmacological approaches have been thoroughly attempted
2. Symptoms are severe, dangerous, or causing significant distress
3. A comprehensive assessment has been conducted to identify potential triggers 1

Common Pitfalls to Avoid

• Rushing to medication: Many clinicians skip non-pharmacological approaches despite evidence showing they should be first-line 1, 4
• Overlooking potential triggers: Pain, infection, constipation, or other medical conditions can cause agitation and should be addressed first 1
• Environmental overstimulation: Crowded places, excessive noise, or unfamiliar surroundings can worsen agitation 2
• Inconsistent routines: Unpredictable schedules can increase confusion and agitation 2

Special Considerations

• Ensure comorbid conditions are optimally treated, as they can contribute to agitation 2
• Register patients at risk for wandering in the Alzheimer's Association Safe Return Program 2
• Provide caregiver education and support, as this can significantly reduce behavioral disturbances 2, 1

If non-pharmacological approaches fail completely, pharmacological options should be considered with careful risk-benefit assessment, starting at the lowest effective dose and monitoring closely for adverse effects 1, 4.