Did You Know? Agitation in Alzheimer’s Dementia

What is Agitation in Alzheimer’s Dementia (AAD)?

AAD is common in individuals with Alzheimer’s dementia and can be a challenging behavioral symptom, characterized by restlessness, irritability, and in some cases, aggression. Effective management requires a comprehensive approach, prioritizing non-pharmacological strategies while carefully considering medication options when necessary. Nearly half of people with Alzheimer’s dementia may experience agitation as disease progresses.

Dementia is a brain disease that is often characterized by persistent or progressive loss of memory, thinking, and decision-making. These deficits make it difficult for an individual living with dementia to perform everyday tasks and activities.

Alzheimer’s disease is one cause of dementia caused by nerve cell (neuron) damage in the brain, making it hard for individuals to remember things and think and speak clearly. Chronic and progressive in nature, Alzheimer’s disease will eventually interfere with the ability to perform the simplest of tasks. Dementia caused by Alzheimer’s disease is known as Alzheimer’s dementia.

Defining and Identifying Agitation in Alzheimer’s dementia

Agitation is when an individual feels upset or restless, expressed verbally or physically, with difficulty remaining calm. Agitated individuals may pace around, repeat verbal cues, act out of character, and even become aggressive towards those around them.

As Alzheimer’s disease progresses, patients may experience behavioral and psychological symptoms, with agitation being the most common. Symptoms of agitation may present as aggressive or non-aggressive behaviors which can be subtle and often missed, such as:

These behaviors are often distressing to the patient and their care environment, and warrant interdisciplinary intervention to target their frequency and severity. The first step is to investigate underlying causes of discomfort that may be contributing to their agitation and behavior.

Underlying Causes of Agitation in Alzheimer’s Dementia

• Unmet needs: Agitation can be a way for individuals to express pain, discomfort, hunger, thirst, or the need to use the bathroom, especially if they have difficulty communicating verbally.
• Environmental triggers: Changes in routine, unfamiliar faces, excessive noise or stimulation, and feeling lost or confused can all contribute to agitation.
• Psychological distress: Depression, anxiety, perceived loneliness and loss of autonomy can lead to agitated behavior.
• Medications and medical conditions: Side effects of certain medications, interactions between medications, or underlying medical conditions like infections can trigger agitation in dementia patients.

Routine interdisciplinary assessment of the individual and evaluation of onset and characterization of agitated behaviors can help determine any modifiable factors in their care plan or environment that are contributing to their agitation.

Strategies for Managing Agitation in Alzheimer’s Dementia (AAD)

The American Psychiatric Association (APA) guidelines and measures from CMS suggest treatment plans for managing agitation in Alzheimer’s Dementia are individualized and follow a patient-centered approach. Once identified, effective non-pharmacological approaches should be detailed and added to the individual’s care plan.

If agitation does not cause significant danger or distress to the individual or others, symptoms are best treated with environmental or behavioral measures. These methods focus on creating a supportive environment and engaging the individual in a positive way, which can reduce the frequency and severity of agitation.

1. Create a Calm and Safe Environment:
   • Reduce Noise and Clutter: Minimize distractions, loud noises, and unnecessary items in their living environment.
   • Maintain Consistent Routines: Establish predictable daily schedules for meals, activities, and bedtime.
   • Ensure Comfort: Check for physical discomfort, such as hunger, thirst, pain, or the need for toileting.
   • Familiar Objects: Keep familiar objects and photos around to provide a sense of comfort and security.
2. Effective Communication:
   • Speak Calmly and Slowly: Use a gentle, reassuring tone of voice and simple language.
   • Validate Their Feelings: Acknowledge and validate the individual’s emotions, even if the cause is unclear.
   • Offer Reassurance: Let them know they are safe and that you are there to help.
   • Avoid Arguing or Correcting: Gently redirect the conversation if the individual is confused or agitated.
3. Meaningful Activities and Engagement:
   • Engage in Enjoyable Activities: Offer familiar activities the individual enjoys, such as listening to music, looking at photos, or gentle exercise.
   • Encourage Physical Activity: Gentle exercise like walking or stretching can help reduce agitation.
   • Reminiscence and Cognitive Stimulation: Consider activities like looking at old photos, listening to music from their past, or engaging in simple puzzles or games.
   • Limit Over-stimulation: Balance activities with quiet time and rest.
4. Responding to Agitation:
   • Stay Calm and Patient: Your own calmness can help de-escalate the situation.
   • Give Space: Avoid crowding the individual and allow them some personal space.
   • Distract or Redirect: Try diverting their attention with a favorite snack, object, or activity.
   • Validate and Forgive: Understand that agitated behaviors are often involuntary and respond with empathy.

Pharmacological Intervention for agitation in AD

Medications should be considered only when non-pharmacological approaches are insufficient to manage agitation, particularly if behavior poses a safety risk to the individual or others.

• Atypical antipsychotics: While these medications can be effective in reducing agitation, they should be used cautiously and at the lowest effective dose due to potential side effects (e.g., falls, sedation, metabolic changes, stroke).
  • All antipsychotic medications (typical and atypical) carry a black box warning for the increased risk of death in elderly patients with dementia-related psychosis.
  • Patients and their families should be informed about the potential risks and benefits of psychotropic therapy before initiation and with dose escalation.
• Antidepressants: May be beneficial if agitation is linked to depression or anxiety, but careful consideration of potential side effects (e.g., increased fall risk with SNRIs) is necessary.
• Other medications: Agents like cholinesterase inhibitors, memantine, or mood stabilizers have been considered, but evidence for their efficacy in treating agitation is less robust.
• Risk-Benefit Assessment: Medications should be routinely reviewed and tapered if agitation stabilizes, efficacy is in question, or adverse effects outweigh the benefits of therapy.

Caregiver Support and Education

Agitation in Alzheimer’s can be very distressing for both the individual experiencing it and their caregivers. Education in disease management techniques and communication strategies can empower caregivers to better care for these individuals and reduce the need for pharmacological interventions.

• essentiALZ®: Developed by the Alzheimer’s Association, this comprehensive program covers key aspects of dementia care and includes certification.
• CARES® Dementia Training & Certification Programs: offers comprehensive dementia care training recognized by CMS with discounts for AHCA / NCAL members.

Additional Resources

1. National Institute on Aging (NIA): Offers resources and publications on Alzheimer’s disease, including tips for caregivers on managing behavioral changes like agitation.
2. Alzheimer’s Association: Provides information and support for individuals with Alzheimer’s and their caregivers, including strategies for managing agitation.
3. Alzheimers.gov: A government website providing information and resources on Alzheimer’s disease and related dementias, including tips for caregivers.
4. Psychiatry.org: The website of the American Psychiatric Association, offering information on mental health conditions, including how to help when dementia leads to agitation.

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