What is the recommended management approach for agitation in dementia?

Management of Agitation in Dementia

Non-pharmacological interventions should be implemented as first-line management for agitation in dementia before considering any pharmacological treatments. 1, 2

Assessment and Identification of Underlying Causes

1. Screen for behavioral changes through interviews with the patient, family members, and healthcare team 1
2. Investigate and treat potential underlying causes of agitation:
   • Pain or discomfort
   • Medical conditions (especially urinary tract infections)
   • Medication side effects
   • Sensory deficits
   • Dehydration
   • Fecal impaction 1, 2
3. Document triggers and patterns using the ABC (antecedent-behavior-consequences) charting approach:
   • Systematically track agitation over several days
   • Identify environmental triggers
   • Record specific behaviors and consequences 1, 2

First-Line: Non-Pharmacological Interventions

Environmental Modifications

• Provide a predictable daily routine (meals, exercise, bedtime) 1
• Create a safe environment (remove sharp furniture, slippery floors, throw rugs) 1
• Install safety features (grab bars, door locks) 1
• Use proper lighting to reduce confusion at night 1
• Reduce excess stimulation (glare, noise, clutter) 1
• Use orientation aids (calendars, clocks, labels) 1
• Consider color-coded or graphic labels as environmental cues 1

Behavioral Strategies

• Use the "three R's" approach: repeat, reassure, and redirect 1
• Implement structured and tailored activities aligned with capabilities and interests 1
• Simplify tasks by breaking them into steps with clear instructions 1
• Use distraction and redirection techniques 1
• For wandering risk, register in the Alzheimer's Association Safe Return Program 1
• Consider activity-based interventions tailored to individual abilities (e.g., Montessori activities) 1

Caregiver Support and Training

• Train caregivers in effective communication techniques (simple commands, calm tones) 2
• Involve family members in developing individualized care plans 2
• Provide caregiver education and support resources 1
• Consider respite care or day programs for patients 1

Second-Line: Pharmacological Interventions

When non-pharmacological strategies fail to reduce behavioral symptoms sufficiently:

1. First consider cholinesterase inhibitors which may improve behavioral symptoms 1

2. If behavioral disturbances persist despite cholinesterase inhibitor therapy:

   • For depression in dementia: SSRIs like citalopram or sertraline (minimal anticholinergic effects) 1
   • For severe agitation with psychotic features: Atypical antipsychotics at lowest effective dose for shortest duration 2
   • For agitation in Lewy Body Dementia: Quetiapine at lowest effective dose 2
   • For agitation in Alzheimer's: Brexpiprazole as recommended 2

Medication Principles

• Start with low doses and increase slowly
• Monitor for side effects
• Increase dosage until adequate response or side effects emerge
• Consider potential drug interactions
• Attempt medication tapering after 6 months of symptom stabilization 1, 2

Important Cautions

• All antipsychotics carry increased mortality risk in elderly patients with dementia 2
• Avoid benzodiazepines as first-line treatment 2
• Avoid medications with high anticholinergic burden 2
• Regularly reassess effectiveness using quantitative measures like the Neuropsychiatric Inventory Questionnaire (NPI-Q) 2

Monitoring and Follow-up

• Assess effectiveness using quantitative measures
• Monitor for medication side effects
• Reassess at least every 6 months
• Discontinue ineffective medications 2
• Attempt medication tapering or discontinuation after 6 months of symptom stabilization 2

The management of agitation in dementia requires a systematic approach that prioritizes non-pharmacological interventions while addressing underlying causes, with pharmacological treatments reserved for when these measures are insufficient.