Publication Highlights Person-Centered Approach to Managing Agitation in Alzheimer’s Disease

Agitation is one of the most distressing behavioral and psychological symptoms of dementia, according to “Insights & Implications in Gerontology: Agitation in Alzheimer’s Disease,” a new publication from The Gerontological Society of America that shares information about approaches and strategies for managing this condition.

Agitation can be described as increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress. It may include nonaggressive behaviors such as pacing, repetitious movements, and general restlessness, or it may manifest as physically or verbally aggressive behaviors.

The prevalence of agitation has been reported to range from 30 to 80 percent of people living with dementia and is more common as the condition advances. Agitation in Alzheimer’s disease (AAD) is associated with many negative outcomes such as accelerated disease progression, physical and mental health deterioration, functional decline, higher risk of admission to long-term care facilities (LTCFs), and poor quality of life. Agitation is one of the most important factors that impacts whether an individual with dementia is placed in a LTCF. Other impacts include increased risk of hospitalization and longer lengths of stay, mental health impairment, higher costs, and increased mortality.

The faculty who oversaw the publication’s development include George T. Grossberg, MD, and Angela Sanford, MD, CMD, of Saint Louis University School of Medicine; Ann Kolanowski, PhD, RN, FGSA, FAAN, of Penn State University; Laura Medders, LCSW, of Emory Integrated Memory Care; and Susan Scanland, MSN, CRNP, GNP-BC, CDP of Dementia Connection, LLC.

Grossberg emphasized that a person-centered approach to care is central to the management of AAD.

“In a person-centered care culture, agitation behaviors are viewed as clues to the presence of distress in a person who is no longer able to communicate an issue through other means,” he said. “The goal of care should be to consider: ‘What is this person expressing, what is causing this reaction, and how can we respond to reduce their distress?’ rather than ‘How do we manage this behavior?’”

In addition to behavioral approaches that may be implemented by caregivers and the person’s care team, the management of AAD may include specific nonpharmacologic modalities such as music or therapeutic touch or pharmacologic approaches. In May 2023, brexpiprazole became the first medication to be approved by the U.S. Food and Drug Administration for the treatment of agitation associated with dementia due to Alzheimer’s disease. Medications used off-label to treat AAD have included benzodiazepines, antihistamines, antidepressants, antiepileptics, and antipsychotics. These agents are limited by only moderate efficacy and most have serious safety and tolerability concerns that are often increased in elderly populations.

Grossberg and his colleagues have developed a treatment algorithm for interventions to ameliorate and prevent agitation that supports the implementation of the International Psychogeriatric Association definition in practice — and is built around a person-centered framework. This decision tree for guiding the management of AAD outlines several steps that should be followed for assessing and managing AAD, starting with ongoing assessment for the emergence of symptoms, differential diagnosis, and nonpharmacologic and pharmacologic treatment approaches.

“Insights & Implications in Gerontology: Agitation in Alzheimer’s Disease” highlights these developments and provides details about person-centered behavioral approaches to AAD, including strategies for care planning, goal setting, and caregiver collaboration. It also provides a framework for how to incorporate other treatment modalities and offers perspectives from clinicians with experience treating patients with AAD. Support for this publication was provided by Otsuka.

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The Gerontological Society of America is the nation's oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,500+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public. GSA’s structure also includes a policy institute, the National Academy on an Aging Society.