What to give for agitation in dementia?

Behavioral and psychological symptoms are highly prevalent in dementia, affecting up to 90% of individuals, with agitation being a common concern.

Understanding what to give for agitation in dementia involves prioritizing non-pharmacological interventions before considering medication, guided by professional medical advice and a deep understanding of the individual's triggers and needs.

Quick Summary

Managing agitation in dementia requires a person-centered approach, focusing first on identifying and addressing underlying unmet needs through behavioral strategies and a calming environment. Pharmacological options, including FDA-approved medications like brexpiprazole and other agents, may be considered cautiously when non-drug methods are insufficient or symptoms pose a significant risk, always in consultation with a doctor.

Key Points

• Prioritize Non-Drug Methods: Start with behavioral and environmental interventions, as they are safer and address underlying causes of agitation.

• Check for Unmet Needs: Always rule out physical discomfort, such as pain, hunger, or a UTI, as a primary trigger for agitation.

• Create a Calm Environment: Reduce noise, clutter, and distractions to minimize stress and overstimulation for the person with dementia.

• Communicate with Empathy: Use a calm tone, simple language, and validation techniques to reassure and connect with the individual's feelings.

• Use Sensory Engagement: Leverage music, touch, and familiar activities to provide comfort and redirection, which can be highly effective.

• Involve Medical Professionals for Medication: Reserve pharmacological interventions for severe, persistent agitation, and only under strict medical supervision due to significant risks.

• Implement a Consistent Routine: Predictable daily schedules can reduce confusion and anxiety, helping to prevent agitated episodes.

Understanding the Root Causes of Agitation

Before considering interventions, it is crucial to recognize that agitation is a form of communication. For an individual with dementia, agitation often signals an unmet need, discomfort, or frustration. Common triggers can include:

• Physical discomfort: Pain from arthritis or other conditions, hunger, thirst, or a full bladder can all lead to agitation.
• Environmental stressors: Loud noises, glare, clutter, or unfamiliar surroundings can be overwhelming.
• Changes in routine: A disruption to a familiar schedule can cause anxiety and confusion.
• Communication difficulties: The inability to express oneself can lead to immense frustration.
• Overstimulation or under-stimulation: Too much activity or too little engagement can be unsettling.

Effective management starts with careful observation to pinpoint these triggers and address them directly. This empathetic approach is the foundation of person-centered care and can often prevent escalation.

Non-Pharmacological Strategies: The First Line of Defense

Non-drug interventions are the recommended first course of action for managing agitation in dementia. These strategies are safer and focus on addressing the individual's needs rather than suppressing symptoms.

Create a Calm and Predictable Environment

• Reduce noise by turning off the television or radio when not being used.
• Ensure soft, even lighting to minimize startling glares or deep shadows.
• Maintain a simple, clutter-free space that is easy to navigate.
• Use familiar objects, photographs, or blankets to provide a sense of security and continuity.

Implement a Consistent Daily Routine

Following a predictable schedule for meals, bathing, and activities can provide structure and reduce anxiety. Planning activities for times of day when the person is typically calmer can be particularly helpful.

Effective Communication and Reassurance

• Speak calmly and slowly: Use a low, reassuring tone of voice.
• Keep it simple: Use short, clear sentences and avoid complex questions.
• Focus on feelings, not facts: Validate the person's emotions rather than correcting them. For example, if they express fear about a “strange man” (their reflection), acknowledge their fear rather than arguing about the fact.
• Use gentle touch: A reassuring hand on the arm can help ground and comfort the person.

Sensory and Engaging Therapies

Sensory-based interventions can be very effective in calming agitation by engaging the senses in a positive way.

• Music therapy: Play familiar or preferred music. Creating a personalized playlist can be a powerful tool for relaxation and reminiscing.
• Aromatherapy: Some individuals respond well to calming scents like lavender.
• Pet therapy: The presence of a calm animal can provide comfort and reduce anxiety.
• Meaningful activities: Engage the person in simple, enjoyable tasks, such as folding laundry, sorting objects, or gardening. These activities provide a sense of purpose.

Manage Underlying Discomfort

• Regularly check for signs of pain, infection, or other medical issues. A urinary tract infection (UTI) can be a common and easily missed cause of increased agitation in older adults.
• Ensure they are not too hot or too cold, and that their clothing is comfortable.
• Offer snacks and drinks regularly to prevent hunger and dehydration.

Pharmacological Options: When to Consider Medication

When non-pharmacological approaches have been exhausted or when the agitation poses a significant risk to the individual or others, a healthcare professional may recommend medication. This should always be done with extreme caution, weighing the potential benefits against serious side effects.

Atypical Antipsychotics

Some antipsychotic medications are used to manage severe agitation, though most carry a US Food and Drug Administration (FDA) “black box” warning for increased mortality risk in elderly dementia patients. The FDA recently approved Brexpiprazole (Rexulti®) specifically for agitation associated with Alzheimer's disease.

• Risperidone (Risperdal®): Effective for severe agitation but has higher risk profile.
• Brexpiprazole (Rexulti®): First FDA-approved medication specifically for this indication, showing efficacy in clinical trials with careful side-effect monitoring.

Antidepressants and Other Agents

For agitation related to anxiety or depression, other medications may be explored.

• Selective Serotonin Reuptake Inhibitors (SSRIs): Citalopram (Celexa®) and sertraline (Zoloft®) have shown some effectiveness for agitation.
• Dextromethorphan/Quinidine (Nuedexta®): Primarily for pseudobulbar affect, it has shown some promise for agitation, but evidence is limited.
• Memantine: This drug, used to treat cognitive symptoms, can sometimes help reduce aggression.

Medication vs. Non-Pharmacological Interventions

Feature	Non-Pharmacological Intervention	Pharmacological Intervention
Primary Goal	Address underlying causes and triggers; enhance quality of life.	Suppress or control behavioral symptoms.
Effectiveness	Often highly effective, especially when personalized and implemented consistently.	Modest effect size, varying by medication and individual.
Side Effects	Minimal to none. Can have positive side effects like increased engagement and mood.	Significant potential for adverse effects, including sedation, confusion, increased fall risk, and metabolic changes.
Risks	Low risk; primarily relates to ignoring underlying medical issues.	Increased risk of serious health issues (e.g., stroke, infection), especially with antipsychotics.
Implementation	Requires caregiver training, patience, observation, and adaptability.	Requires careful medical supervision, dose titration, and regular monitoring for efficacy and safety.
Approach	Person-centered, empathetic, holistic.	Symptom-focused, often last-resort.

A Balanced Approach: Combining Strategies

The most effective strategy is often a dynamic combination of both approaches, with non-pharmacological methods as the first and primary step. Caregivers should be trained in recognizing and de-escalating agitation effectively. For persistent or severe cases, the selective and cautious use of medication, prescribed by a specialist, can provide relief while continuing to prioritize behavioral support. Regular communication with the healthcare team is essential to monitor progress and adjust treatment plans as needed. The ultimate goal is to improve the quality of life and dignity for the individual with dementia.

For additional support and strategies in managing agitation, consider resources like the National Institute on Aging (NIA), which provides comprehensive guides for caregivers.

Frequently Asked Questions

What is the first step to address agitation in dementia?

The first step is always to investigate potential non-medical causes, such as unmet needs like pain, hunger, or boredom, or environmental triggers like loud noises or a confusing routine. Non-drug interventions are the safest first line of defense.

Are there any FDA-approved medications for dementia agitation?

Yes, as of recently, Brexpiprazole (Rexulti®) has been FDA-approved specifically for the treatment of agitation associated with Alzheimer's disease. However, its use still requires careful medical consideration due to potential risks.

Can music help calm agitation in dementia?

Yes, music therapy is often very effective. Playing familiar, personalized music can soothe, reduce anxiety, and provide a positive distraction. An individualized approach with preferred music is most successful.

What are the risks of using antipsychotic medication for agitation?

Antipsychotics carry significant risks for older dementia patients, including increased risk of stroke, falls, sedation, and a 'black box' warning for increased mortality. They should be used cautiously, at the lowest effective dose, and for the shortest possible duration.

How can a caregiver use distraction to manage agitation?

Distraction involves gently redirecting the person's attention to a pleasant or calming activity. This could be offering a favorite snack, going for a short walk, or looking at a familiar photo album. The goal is to shift focus away from the source of distress.

Does anxiety or pain increase agitation in dementia?

Yes. A person with dementia may have difficulty verbalizing that they are in pain or feeling anxious. This distress can then manifest as agitated behavior. Caregivers should be vigilant for non-verbal cues indicating pain or discomfort.

What is 'sundowning' and how is it managed?

Sundowning is a state of increased confusion and agitation that occurs in the late afternoon and evening. To manage it, maintaining a consistent routine, increasing daytime activity, and creating a calm, well-lit evening environment can help reduce symptoms.