Agitation and aggression (BPSD)

What agitation and aggression look like

Agitation in dementia is a state of internal distress that shows as restlessness, repetitive movements, pacing, calling out, irritability or sleep disturbance. Aggression is action towards self or others: verbal abuse, threatening gestures, physical pushing, hitting or kicking. Both are common in moderate dementia, with reported prevalence of 40 to 60 per cent at some point during the illness.

The first thing to know is that agitation and aggression are not character failings. They are responses to internal or external stressors that the person can no longer process or communicate in the usual ways.

Identifying the trigger

NICE NG97 1.7 recommends a structured search for the cause before considering medication. The acronym PINCH-ME covers the commonest reversible contributors:

• Pain (often unrecognised; observe for grimacing, guarding, change in mobility);
• Infection (especially urinary tract infection and chest infection);
• Nutrition and dehydration;
• Constipation;
• Hydration;
• Medication (recent changes, anticholinergic burden, polypharmacy);
• Environment (over-stimulation, sleep disturbance, unfamiliar setting).

Other common triggers include sensory impairment (uncorrected hearing or vision), fear, boredom, communication difficulty, recent loss or bereavement, change in routine, and difficult interactions with people around them.

Non-pharmacological approaches

Non-pharmacological interventions are first-line. Several have an evidence base.

Person-centred approaches

The Dementia Care Mapping and similar person-centred care frameworks emphasise understanding the person's biography, preferences, sensory environment, social engagement and unmet needs. Care that is consistently person-centred reduces BPSD measurably.

Environmental modification

Reducing noise, glare, clutter and competing stimuli. Familiar objects, music, photographs and routine. Good lighting in the late afternoon helps with sundowning.

Meaningful activity

Boredom is a major driver of agitation. Activities matched to the person's interests and current abilities (sorting, folding, gardening, music, reminiscence, walking) reduce restlessness.

Communication adjustments

Short, single-message sentences. Calm tone. Approach from the front, at eye level. Allow time to respond. Avoid "no", "do not" and testing-style questions. See communicating with someone with dementia.

Music, aromatherapy and pet therapy

Music selected by the person (or by family) is one of the strongest non-pharmacological interventions for agitation. Aromatherapy (lavender, lemon balm) and pet therapy have a smaller but consistent evidence base.

Validation Therapy

Validation Therapy is an approach to communication that focuses on the underlying emotion rather than the factual content. A person who says "I want to go home" may be expressing distress, not a literal request. Acknowledging the feeling, even when the facts cannot be agreed, often calms.

When medication is used

NICE NG97 recommends pharmacological treatment of BPSD only when:

• The behaviour is severe;
• The person, or those around them, is at risk of harm;
• Non-pharmacological approaches have been tried adequately and failed.

Cholinesterase Inhibitors and Memantine

In Alzheimer's Disease and Dementia with Lewy Bodies, optimising the dose of a Cholinesterase Inhibitor or adding Memantine can reduce behavioural symptoms. This is often a useful first medication step.

Antidepressants

Selective Serotonin Reuptake Inhibitors (Citalopram, Sertraline, Mirtazapine) can help where depression, anxiety or irritability are prominent. Citalopram has the strongest evidence base for agitation specifically (CitAD trial) but requires monitoring of QT interval, particularly in older adults.

Antipsychotics

Risperidone is the only antipsychotic licensed in the UK for short-term treatment of persistent aggression in Alzheimer's Disease where non-pharmacological approaches have not worked. The typical dose is 0.25 to 0.5 mg twice daily for up to 6 weeks, with review.

All antipsychotics in older adults with dementia carry an increased risk of stroke and all-cause mortality. The decision to prescribe requires a clear discussion of risks and benefits, and ideally the person's prior wishes via an advance care plan. Antipsychotics are contraindicated or used with extreme caution in Dementia with Lewy Bodies.

Short-term sedatives

Lorazepam at low dose (0.25 to 0.5 mg) is occasionally used for acute severe agitation. Benzodiazepines should not be used routinely because they worsen confusion, falls and cognition.

Acute escalation: what to do

If a person becomes acutely agitated:

• Make sure both of you are safe. Step back if needed. Do not corner the person.
• Reduce stimulation: lower noise, turn off the television, dim bright lights.
• Use a calm, slow voice. Use the person's name. Validate the feeling ("I can see you are upset").
• Offer choices, not demands ("Would you like to sit down or walk outside?").
• If a medical cause is suspected (sudden change, fever, pain), call NHS 111 or 999.
• If you are not safe and de-escalation is not working, leave the room and call for help.

For Carers

Agitation and aggression are exhausting and often shameful for the family member who experiences them. Carer stress and burnout drive worsening behaviour through a feedback loop. Three things help:

• Take breaks. Respite care, an Admiral Nurse home visit, or a Memory Cafe with someone else present provides relief;
• Join a carer support group; agitation is one of the topics most discussed there;
• Seek professional advice early. Early intervention prevents the escalation that leads to crisis.

When to seek specialist help

Three thresholds prompt specialist input:

• Severe or persistent agitation despite reasonable environmental and behavioural measures;
• Aggression putting the person or those around them at risk;
• Any consideration of antipsychotic medication.

Specialist support is available via the local memory clinic, older adult psychiatry teams, the Alzheimer's Society Dementia Connect Support Line, the Dementia UK Admiral Nurse Helpline, or The Dementia Service for private review.