Agitation is defined as inappropriate physical or verbal activity. The resulting behaviour can be either aggressive or non-aggressive. Examples of non-aggressive behaviours are pacing, wandering, repetitive actions or speech, complaining, and interrupting. Aggressive behaviours include shouting or hitting.

What are possible causes of agitation in dementia?

Medical illnesses
A behaviour disturbance may be the only sign of a medical problem in people with dementia. They can become agitated if they are constipated, dehydrated, in pain, or develop an infection. Deterioration from any ongoing medical condition can also be a cause.

Delirium
Delirium is an acute state of confusion that can lead to excess activity and a reduced attention span. It is often caused by a medical problem such as an underactive thyroid, an infection, and drugs. Delirium always needs to be ruled out when a person with dementia becomes agitated.

Environmental stress
People with dementia like regular predictable routines. Any change in their environment can trigger agitation. Triggers include a change in activity schedule, diet, noise level, visual stimulation or even a new caregiver.

Medications
Both over-the-counter and prescription drugs can make some people agitated. Drugs such as steroids, antispasmodics and antidepressants can be the cause. Withdrawal from alcohol, narcotic pain medications and sedatives can also lead to agitation in dementia.

Psychiatric disorders
Depression, mania, anxiety, and psychosis are some conditions that can cause agitation in people with dementia. Examples of behaviours that show mania are racing thoughts and rapid, pressured speech. With psychosis, the person may see or hear things that aren’t there. For example, they may worry that their belongings are being stolen when this isn’t happening.

Dementia
Dementia itself can be a significant cause of behaviour problems. However, the above causes must be considered and ruled out before assuming that dementia is causing the behaviour problems.

How is agitation in dementia treated?

Non-medication interventions

Behaviour and environment changes are used to help manage behaviour symptoms in dementia.

Behaviour changes

Therapeutic touch
Touch, such as holding someone’s hand, can often convey a message of caring, but it may also trigger agitation if the person wants to be left alone. An individual approach, depending on the person’s response, is necessary.

Diversion
Diversion tactics deflect people from their agitation by engaging them in a task. Involving them in conversation or a social activity are effective examples of this.

Validation
Validation focuses on the emotional content of what someone is saying, rather than the facts of the conversation. The emotion being expressed by the person is acknowledged. "You sound happy about that" or "It sounds like you are feeling sad right now" are examples.

Communication
It is important to have simple verbal communication with people with dementia. Use a low-pitched voice, and speak clearly and slowly. Short, concrete statements are best to help the person understand what is being said. As well, questions should be phrased so that they can be answered simply, such as with a yes or no response. Nonverbal communication also needs to be done carefully. Tense posture, frowning and rapid movements are seen as unfriendly. Instead, a calm approach, keeping eye contact, and a relaxed posture are best. Try to match your verbal and nonverbal signals.

Changes to the environment

Stimulation
Seeing and hearing too many things at once can overwhelm a person with dementia. Too much noise from television and radio, lights, and excessive movement can be very distressing for them. Keeping the person in a calm, quiet, and familiar environment helps.

Regular schedule
Those with dementia need a daily routine of activities at predictable times with familiar persons. A schedule without change helps them remember and reduces their anxiety.

Restraint free environment
Restraints do not reduce falls or injury. In fact, restraint use can result in injury. As well, problems related to lack of movement (pressure sores and muscle weakness) can occur. Restraints should be avoided as much as possible and their need should first be discussed with the patient’s doctor.

Music
Music can be soothing for some people with agitation and dementia, particularly music with which they are familiar.

ABC Method
A - antecedent (before the event), B - behaviour and C - consequences. The ABC method tries to find the triggers of the agitation. Caregivers should keep a diary of the person’s behaviour. Try to identify the event that happened before the agitation began. Note the agitated behaviour that followed the event, and anything that changed the behaviour. By changing the environment according to what is found, the agitation can be reduced. The following is an example. A - the person is watching the hockey game on TV, B - becomes anxious and speaks loudly, C - behaviour stops when the TV is turned off. In this case, the hockey game on TV is the problem. If this usually causes agitation, it may need to be avoided.

Using medication

Medications are used if caregiver behaviour and environment changes fail to reduce the patient’s disruptive behaviours or if the patient’s behaviour becomes dangerous. A wide variety of medications can be used. Not all behaviours, however, are changed by medications. For other conditions, medication can make a difference. The type of drug chosen depends on the cause of the agitation. When a medication is used the person should be checked for effectiveness and for side effects.

Agitation can be a significant problem in dementia. Any individual with new or worsening behaviour changes needs to see a doctor help to discover the causes. The best initial approach is to try methods that do not use medication. However, these alone may not be enough. If the behaviours cannot be controlled, the addition of medication needs to be considered.

Remember that you are not alone in this. Good communication between you and your doctor can help when caring at home for a loved one with dementia.

Coping with Agitation in Dementia Suggestions for family caregivers