What’s the best way to manage agitation related to dementia?

You notice your loved one becoming more forgetful. She cannot recall her visit with her granddaughters yesterday. She claims she took her medications this morning, yet you find them untouched in her pill case. You wonder how this mild-mannered woman has become so angry, so quickly. She is often frightened now, disoriented, and unpredictable. Yet she still remembers every detail of your wedding day, the names of your four children, and how to play her favorite piano pieces. When you sing together, time temporarily stands still.

Your loved one received a diagnosis of Alzheimer’s disease. Nights are the hardest time for her. You worry about her safety when she wanders through the house. She almost broke the door last week; you can tell her arm still hurts when you bathe her. She resists and yells at you when you take her to the bathroom. She has started to show behavioral symptoms of dementia.

Aggression and agitation in dementia

Behavioral and psychological symptoms are very common in dementia, and affect up to 90% of people living with dementia. In addition to memory changes, people with dementia may experience agitation, psychosis, anxiety, depression, and apathy. These behavioral symptoms often lead to greater distress than memory changes.

When people with dementia become agitated or aggressive, doctors often prescribe medications to control their behaviors in spite of the known risks of serious side effects. The most frequently prescribed medication classes for agitation in dementia carry serious risks of falls, heart problems, stroke, and even death.

Caregivers, who often experience burnout in managing aggressive behaviors, welcome medications that can temporarily decrease agitation. Unfortunately, aggressive and agitated behavior often contributes to the decision to transition a loved one to an alternative living situation.

New research shows that nondrug therapies are more effective

According to a new study looking at more than 160 articles, nondrug interventions appeared to be more effective than medications in reducing agitation and aggression in people with dementia. Researchers found that three nonpharmacologic interventions were more effective than usual care: multidisciplinary care, massage and touch therapy, and music combined with massage and touch therapy.

For physical aggression, outdoor activities were more efficacious than antipsychotic medications (a class of drugs often prescribed to manage aggression). For verbal aggression, massage and touch therapy were more effective than care as usual. As a result of this study, the authors recommend prioritization of nonpharmacologic interventions over medications, a treatment strategy also recommended by the practice guidelines of the American Psychiatric Association.

Helpful tips for caregivers

To decrease agitation and aggression with dementia, caregivers can help their loved ones in the following ways:

• Find a multidisciplinary team of specialists. This may include a psychiatrist to carefully consider the risks and benefits of medications for managing behavior, a geriatrician to optimize your loved one’s medical situations, and an occupational therapist to consider modifications of a person’s living environment and daily routine.
• Go for a walk or on an outing for a change of scenery. Physical activity has additional benefits on mood, memory, and lowering anxiety.
• Add massage and touch therapy, or just provide a calming hand massage.
• Incorporate music into your loved one’s daily routine.
• Notice the first signs of agitation. Nondrug options work best the earlier they are used.
• Get creative: discover what works and try using different senses. Aromatherapy, an activity such as folding (and refolding) laundry, brushing hair, or dancing can all be calming.
• Consult with your physicians. Medications are often prescribed as first-line interventions despite what we know about the effectiveness of nondrug options.
• Educate all the people caring for your loved one on the interventions that work best, and check in with them about how these approaches are working.

The bottom line

To decrease agitation and aggression in people with dementia, nondrug options are more effective than medications. Physical activity, touch and massage, and music can all be used as tools to manage agitation related to dementia.