Expert Consensus Highlights Evidence-Based Recommendations for Managing Agitation in Alzheimer Dementia
Agitation is one of the most distressing and disruptive behavioral symptoms of Alzheimer dementia, affecting approximately one-half of all patients and placing a significant burden on caregivers and health care systems. In response to new evidence and evolving treatment options, a multidisciplinary panel of experts convened a consensus roundtable in October 2024 to develop practical, evidence-based recommendations for US primary care providers managing agitation in Alzheimer dementia.
The experts emphasized that early identification of agitation relies on open, active communication between health care providers, patients, and caregivers. Because caregivers are often the first to observe behavioral changes, clinicians should routinely inquire about new or worsening agitation symptoms using clear, patient-centered language. Providing accessible educational materials and using structured assessment tools—such as the International Psychogeriatric Association’s criteria or the Gerontological Society of America’s decision tree—can aid in accurate diagnosis and differentiation from other causes such as infection, pain, or medication side effects.
The roundtable reaffirmed that treatment should always begin with individualized nonpharmacologic strategies tailored to the patient’s background, interests, and level of functioning. Evidence from randomized controlled trials supports interventions including aromatherapy, music therapy, acupressure, animal-assisted activities, and structured sensory modulation approaches. These interventions are low-risk but resource-intensive, underscoring the need for caregiver education and institutional support to ensure sustainability in residential care settings. A consistent daily routine with meaningful activities is strongly recommended to reduce agitation and enhance patient engagement.
Pharmacologic therapy should be reserved for cases where agitation is severe, poses safety risks, or fails to respond to behavioral measures. While several off-label agents—such as risperidone, quetiapine, citalopram, and nabilone—have shown some benefit, their use must be weighed against potential adverse effects, including increased mortality with antipsychotics in older adults. Importantly, brexpiprazole is currently the only US Food and Drug Administration (FDA)–approved medication for agitation associated with Alzheimer dementia, demonstrating moderate but clinically meaningful efficacy with a favorable safety profile. Clinicians are advised to use scheduled dosing and titration to achieve therapeutic benefit.
Effective management requires ongoing communication among healthcare teams, caregivers, and residential facility staff. Clinicians should document treatment goals, monitor efficacy and side effects, and regularly reassess caregiver well-being to mitigate burnout. Educational resources, telehealth check-ins, and adherence to Centers for Medicare & Medicaid Services (CMS) guidelines for informed consent are essential to optimizing patient safety and outcomes.
This expert consensus underscores that agitation in Alzheimer dementia demands a proactive, multidisciplinary, and person-centered approach. Combining early detection, individualized nonpharmacologic care, judicious pharmacologic treatment, and caregiver support can improve quality of life for patients and families alike.
Reference
Grossberg GT, Sanford A, Montano CB, et al. A US-based practitioner's guide to diagnosis, evaluation, and evidence-based treatment of agitation in Alzheimer's dementia - recommendations of an expert, multispecialty advisory panel. Postgrad Med. 2025;137(6):469-485. doi:10.1080/00325481.2025.2517535
