Agitation or Aggression

Seen in up to 80% of patients with Alzheimers disease
A leading cause of nursing-home admission
Identify and examine context of behavior (is it harmful to patient or others?) and environmental triggers (eg, overstimulation, unfamiliar surroundings, frustrating interactions).
Determine whether delusions or hallucinations are interfering with function.
Exclude underlying physical discomfort (eg, pain or hunger).
Always consider nonpharmacologic strategies first:
- Advise caregiver(s) to:
  - Use scheduled toileting and prompted toileting for incontinence.
  - Offer graded assistance (as little help as possible to perform ADLs), role modeling, cueing, and positive reinforcement to increase independence.
  - Avoid adversarial debates; try to redirect conversation instead.
  - Maintain a calm demeanor.
  - Use services of caregiver support groups.
- For problem behaviors:
  - Music during meals, bathing
  - Walking or light exercise
  - Simulate family presence with video or audio tapes
  - Pet therapy
  - Speak at patients comprehension level
  - Bright light, “white” noise (ie, low-level, background noise)
For intermittent disruptive behaviors (once per week or less), identifying antecedents of the behavior and avoiding triggers is often most useful. Behavior modification using positive reinforcement of desirable behavior has been shown to be effective, and also helps caregiver focus on times when behavior is not a problem.
Physical restraint in any form should be avoided if at all possible. If restraining measures are necessary, careful supportive care should be provided to the patient. Over time, it is usually possible to reduce or eliminate the amount of restraint.
Select pharmacologic agent on the basis of symptoms (see Table 6).
Cognitive enhancers may slow deterioration, and agitation may worsen if they are discontinued.
Low dosages of antipsychotic medications have a limited role but may be necessary at times. Note: this use is “off label;” use in AD patients has a BLACK BOX warning because the risk of death was higher with drug treatment than with placebo in clinical trials. Risk-benefit must be discussed with patients, surrogate decision-makers, families, and/or caregivers before starting treatment (see Studies regarding excess mortality associated with antipsychotic medication use in patients with dementia, and References ).