What is the initial approach to managing agitation in dementia?

Work-Up for Agitation in Dementia

Step 1: Systematically Describe and Characterize the Behavior

The first critical step is to obtain a detailed, contextual description of the agitation using the "DESCRIBE" approach—asking caregivers to replay the behavior "as if in a movie" to identify specific antecedents, the exact nature of the behavior, and consequences. 1

• Document when the agitation occurs, what triggers it, how the patient responds, and what happens afterward using ABC (antecedent-behavior-consequence) charting 1, 2
• Ask caregivers to keep a diary tracking agitation episodes over several days to identify patterns 1, 3
• Clarify what the caregiver means by "agitation"—this term encompasses anxiety, repetitive questions, aggression, wandering, and verbal outbursts, each requiring different management 1
• Elicit the patient's perspective directly when possible to understand their experience and what aspect is most distressing 1
• Quantify baseline severity using a standardized tool such as the Cohen-Mansfield Agitation Inventory or Neuropsychiatric Inventory Questionnaire (NPI-Q) to establish objective measures for monitoring treatment response 4, 2

Step 2: Investigate Underlying Medical and Environmental Causes

Before any treatment, systematically rule out reversible medical causes that commonly precipitate agitation in dementia patients who cannot verbally communicate discomfort. 4, 2

Medical Causes to Investigate:

• Pain (the single most common contributor to behavioral disturbances in non-verbal patients) 4, 3
• Infections: urinary tract infections, pneumonia, and other systemic infections 4, 2
• Constipation and urinary retention 1, 4
• Dehydration 4
• Hypoxia 4
• Medication side effects, particularly anticholinergic medications that worsen agitation 4, 2
• Sensory impairments (hearing or vision problems that increase confusion and fear) 4

Environmental Assessment:

• Evaluate environmental safety including access to hazardous items, fall risks, and need for assistive devices like handrails 2, 3
• Assess for overstimulation, excessive noise, inadequate lighting, or chaotic surroundings 2, 3
• Review medication list for drug toxicity or adverse effects 4

Step 3: Implement Non-Pharmacological Interventions First

Non-pharmacological interventions are first-line treatment and must be attempted and documented as failed before considering medications, as they have substantial evidence for efficacy without mortality risks. 1, 4, 5

Communication Strategies:

• Use calm tones, simple one-step commands, and gentle touch for reassurance rather than complex instructions 4, 3
• Allow adequate time for the patient to process information before expecting a response 4
• Avoid harsh tones, yelling, or open-ended questions 3

Environmental Modifications:

• Establish a predictable daily routine with regular timing for exercise, meals, and bedtime 2, 3
• Optimize lighting to reduce confusion, particularly at night, while avoiding glare from windows and mirrors 2
• Simplify the environment by reducing clutter and avoiding overstimulation 2, 3
• Use orientation aids including calendars, clocks, color-coded labels, and graphic cues for navigation 2, 3
• Install handrails near toilets and in showers for safety 3

Activity-Based Interventions:

• Implement structured, individualized activities that match the patient's current cognitive abilities and incorporate their previous roles and interests 2, 3
• Consider music therapy and other personalized non-pharmacological approaches 6
• Use the TREA (Treatment Routes for Exploring Agitation) methodology to address specific unmet needs based on the person's past identity, preferences, and abilities 5

Timing and Approach to Care:

• Time care activities when the patient is most calm and receptive 4
• Question whether the patient must get out of bed—consider whether care can be provided in bed instead 4
• Use physical therapy consultation to develop gentler transfer techniques 4
• Ensure adequate pain management before attempting care activities 4

Step 4: Consider Pharmacological Treatment Only When Appropriate

Medications should only be used when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have been thoroughly attempted and documented as insufficient. 1, 4

Criteria for Pharmacological Intervention:

• Severe agitation that is dangerous or causes significant distress to the patient 1, 4
• Non-pharmacological approaches have failed after adequate trial (typically 24-48 hours to several weeks depending on acuity) 4
• Emergency situations with imminent risk of harm 4

Risk/Benefit Discussion Required:

Before initiating any medication, discuss with the patient (if feasible) and surrogate decision maker the increased mortality risk (1.6-1.7 times higher than placebo), cardiovascular effects including sudden death, cerebrovascular adverse reactions including stroke, falls, metabolic changes, and expected benefits and treatment goals. 1, 7

First-Line Pharmacological Options for Chronic Agitation:

SSRIs (Preferred for Non-Psychotic Agitation):

• Citalopram: Start 10 mg/day, maximum 40 mg/day 4, 2
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day 4
• Avoid paroxetine due to anticholinergic effects that worsen cognition 2
• Assess response within 4 weeks using the same quantitative measure used at baseline 1, 2
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 1, 2

Second-Line Option:

• Trazodone: Start 25 mg/day, maximum 200-400 mg/day in divided doses when SSRIs have failed or are not tolerated 4
• Use caution in patients with premature ventricular contractions due to risk of orthostatic hypotension 4

Antipsychotics (Reserved for Severe Agitation with Psychotic Features):

Antipsychotics should only be used at the lowest effective dose for the shortest possible duration, with daily reassessment, and only when behavioral interventions have failed. 1, 4

Atypical Antipsychotics:

• Risperidone: Start 0.25 mg at bedtime, maximum 2-3 mg/day in divided doses (extrapyramidal symptoms increase at doses ≥2 mg/day) 4, 7
• Quetiapine: Start 12.5 mg twice daily, maximum 200 mg twice daily (more sedating with risk of orthostatic hypotension) 4
• Olanzapine: Start 2.5 mg at bedtime, maximum 10 mg/day (less effective in patients over 75 years) 4

For Acute Severe Agitation:

• Haloperidol: 0.5-1 mg orally or subcutaneously, maximum 5 mg daily in elderly patients 4
• Use only when patient is severely agitated with imminent risk of harm to self or others 4

Medications to AVOID:

• Typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use 4
• Benzodiazepines for routine use due to risk of tolerance, addiction, cognitive impairment, paradoxical agitation in 10% of elderly patients, and increased delirium 4
• Cholinesterase inhibitors should not be newly prescribed to prevent or treat agitation, as they have been associated with increased mortality 4
• Thioridazine, chlorpromazine for behavioral symptoms 3

Step 5: Monitor Response and Reassess Regularly

Evaluate response within 4 weeks (30 days) of initiating pharmacological treatment using the same quantitative measure used at baseline. 1, 2

• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 1, 2
• Evaluate ongoing use daily with in-person examination when using antipsychotics 4
• Monitor for side effects including extrapyramidal symptoms, falls, metabolic changes, QT prolongation, and cognitive worsening 1, 7
• Even with positive response, periodically reassess the need for continued medication through shared decision-making with patient/surrogate 1, 2
• Consider gradual dose reduction or discontinuation after 6 months of symptom stabilization 3
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—inadvertent chronic use must be avoided 4

Critical Pitfalls to Avoid

• Never rely exclusively on pharmacological interventions without implementing non-pharmacological strategies first 3
• Never use antipsychotics for mild agitation—reserve them only for severe, dangerous symptoms 4
• Never continue antipsychotics indefinitely—review need at every visit and taper if no longer indicated 4
• Never underestimate pain as a cause of agitation in patients who cannot verbally communicate discomfort 4, 3
• Never use medications with significant anticholinergic effects (like diphenhydramine or paroxetine), which worsen cognitive symptoms and agitation 4, 2
• Never fail to discuss mortality risks (increased 1.6-1.7 times) before initiating antipsychotics 1, 7
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine 4