What are the American Association for Geriatric Psychiatry (AAGP) recommendations for managing agitation in dementia?

American Association for Geriatric Psychiatry Recommendations for Agitation Management in Dementia

First-Line Approach: Non-Pharmacological Interventions

Non-pharmacological interventions should be implemented as first-line management for agitation in dementia, focusing on identifying and addressing underlying causes through comprehensive assessment of the patient, environment, and caregivers. 1

Assessment Process

• Thoroughly characterize behavior and context:
  • Document specific triggers and patterns using ABC (antecedent-behavior-consequences) charting
  • Identify what aspects are most distressing to patient and caregiver
  • Screen for potential underlying causes:
    • Pain or discomfort
    • Medical conditions
    • Medication side effects
    • Sensory deficits
    • Dehydration
    • Fecal impaction
    • Psychiatric conditions

Environmental Modifications

• Create a dementia-friendly environment:
  • Ensure adequate lighting
  • Reduce noise and sensory overload
  • Provide clear signage and color-coding
  • Create quieter, supervised spaces
  • Ensure access to food, drink, and toileting facilities
  • Maintain familiar objects in the environment 1

Behavioral Interventions

• Implement structured daily routines
• Use distraction and redirection techniques
• Simplify tasks to match cognitive abilities
• Provide tailored activities (e.g., Montessori activities)
• Teach caregivers effective communication techniques:
  • Use simple commands
  • Maintain calm tones
  • Use reassuring touch when appropriate 1

Pharmacological Management

When non-pharmacological approaches are insufficient, medication may be considered with careful attention to risks and benefits.

First-Line Pharmacological Options

• Cholinesterase inhibitors may be considered first-line for behavioral symptoms 1
• For severe symptoms with psychotic features, atypical antipsychotics are appropriate first-line pharmacological treatment:
  • Use lowest effective dose
  • Prescribe for shortest duration possible
  • Attempt medication tapering after 6 months of symptom stabilization 1

Medication Options Based on Presentation

1. For agitation in Lewy Body Dementia:

   • Quetiapine at lowest effective dose for shortest duration 1

2. For agitation in Alzheimer's dementia:

   • Brexpiprazole as recommended by manufacturer 1

3. For general agitation in dementia:

   • Trazodone: 25 mg/day initial dose, 200-400 mg/day maximum dose
   • Gabapentin for behavioral and psychological symptoms of dementia (BPSD)
   • Haloperidol: 0.5-1 mg orally at night and every 2 hours when required (maximum 5 mg daily in elderly)
   • Lorazepam: 0.25-0.5 mg orally four times a day as required (maximum 2 mg in 24 hours) 1

Caregiver Support and Education

• Involve family members in developing individualized care plans
• Provide education on dementia progression and management strategies
• Consider respite care or day programs to reduce caregiver burden
• Establish cross-professional service teams to support caregivers 1

Monitoring and Follow-up

• Assess effectiveness using quantitative measures like Neuropsychiatric Inventory Questionnaire (NPI-Q)
• Monitor for medication side effects
• Reassess at least every 6 months
• Discontinue ineffective medications
• Consider combination pharmacotherapy only after failed trials with two different classes of agents at sufficient doses 1

Important Considerations and Pitfalls

1. Medication risks: Antipsychotics carry black box warnings for increased mortality in elderly patients with dementia. Balance risks against potential benefits.

2. Underlying causes: Agitation often has multiple contributing factors including pain, which may be underreported in dementia patients. Evaluate for pain-related behaviors rather than relying solely on self-reporting 1.

3. Sundown syndrome: Agitation often worsens in late afternoon and evening, requiring specific environmental and pharmacological strategies 2.

4. Pandemic considerations: The COVID-19 pandemic has increased agitation incidence among dementia patients, requiring additional attention to prevention and management strategies 3.

5. Avoid overmedication: The goal is symptom management with minimal medication side effects, not complete elimination of all behaviors 1, 4.