How I Treat: Agitation in Alzheimer Disease

In this expert interview, Rajesh Tampi, MD, shares a patient-centered, team-based framework for managing agitation in Alzheimer disease, emphasizing individualized care plans, nonpharmacologic strategies, and careful use of medications across long-term care settings.

Key Takeaways:

• Individualized, patient-centric care is essential in managing agitation in Alzheimer disease, with accurate diagnosis, caregiver input, and tailored treatment plans forming the foundation of effective care.
• Nonpharmacologic interventions are the cornerstone of dementia-related agitation management, including caregiver education, redirection, reminiscence therapy, music therapy, and other personalized behavioral strategies.
• Pharmacologic treatment should be used cautiously and selectively, reserved for nonemergent behaviors that do not respond to nonpharmacologic approaches or for true psychiatric emergencies, with ongoing monitoring for efficacy and adverse effects.

Please introduce yourself by stating your name, title, and any relevant clinical experience you'd like to share.

Rajesh R. Tampi, MD, MS, FAPA: Hello, everyone. My name is Rajesh Tampi. I'm the chairman of the department of psychiatry at Creighton Medical School. I'm also the medical director of the CHI Behavioral Health Services in Omaha, Nebraska. I'm the past president of the American Association for Geriatric Psychiatry (AAGP) and the inaugural historian of AAGP.

How do you ensure a patient-centric approach in the treatment of agitation associated with Alzheimer disease? Are there particular strategies or care models you’ve implemented to provide individualized management that addresses both behavioral symptoms and underlying unmet needs?

Dr Tampi: That's an excellent question. All care of patients, whether they are older adults or not, should be patient-centric. Every patient should have an individualized treatment plan.

The same thing applies to individuals who have agitation with Alzheimer disease. When we see the patient initially, we gather information from the patient and collateral sources. We go through the relevant medical history. We go through the relevant psychiatric history, family history, social history, and medications and allergies. We perform a good mental status examination. We do appropriate lab work. We do a focused physical examination and order associated tests, like an MRI, CT scan, or PET scan, as needed. We do neuropsychological testing when there is a question. We also do urine drug scans because many of these individuals may be using substances of abuse.

We want to rule those things out before we implement a treatment plan for agitation in Alzheimer disease.

Have you incorporated any technology-enabled tools or digital platforms to aid in the monitoring or management of agitation in Alzheimer disease? If so, how have these tools supported earlier detection, improved symptom tracking, or enhanced adherence to care plans?

Dr Tampi: We are still in the infancy of using technology and artificial intelligence (AI) in the care of individuals with dementia. We are now doing Zoom visits for patients who are not able to come to our clinics. It's much easier for the families to be able to have them evaluated [that way]. We use that for initial visits. We also do that for follow-up visits.

For treatment plans, we are using technology, like playing video loop tapes so that patients can be feeling connected with their families. That's what we have done [so far].

In terms of using technology in other ways, we have used technology in gathering information and gathering protocols to help us develop a treatment plan for each of our patients.

Can you walk us through your typical treatment protocol for managing agitation in Alzheimer disease? What pharmacologic and nonpharmacologic interventions do you find most effective, and how do you tailor these approaches based on stage of disease, comorbidities, and caregiver dynamics?

Dr Tampi: Again, an excellent question. Like I said, first, you have individualized treatment plans. Getting a good history and getting good collateral information [is important]. Make sure that the diagnosis is correct and that the patient has Alzheimer disease versus vascular disease versus mixed dementias versus frontotemporal dementia or Lewy body disease, because you have to be a little more careful when you have patients with Lewy body disease or vascular dementia. These patients tend to either not tolerate medications as well or have more adverse effects when using the medications. Each patient has their individualized treatment plan center for Medicare and Medicaid services, [you should] indicate that that should be there for each of the patients.

Nonpharmacologic managements are the cornerstone of treating patients with behavioral symptoms of dementia. We design our nonpharmacologic management depending on the kinds of symptoms that the patient actually presents with. It is important to remember that the nonpharmacologic management that has been shown to be of most benefit is educating caregivers and educating professionals so that they know that they should apply that as a first step.

There are many other kinds of nonpharmacologic managements that have been found to be helpful. Redirection is one, reminiscence therapy is another, music therapy is another, recreational therapy is another, and using pet robots is another one. It depends on what is available to the patient and what can be implemented by the family.

We only use pharmacological management if nonpharmacologic management is either ineffective or only partially effective. It depends upon the kind of symptoms patients present with. You can divide the symptoms into emergent behaviors and emergent behaviors of psychiatric emergencies; those cannot be treated at home. Those cannot be treated in the outpatient clinic; those have to be managed like a psychiatric emergency, and the patient has to go to the emergency room. We may, in those situations, call the police or call the ambulance so that the patient can be transported safely to the emergency room and also to make sure that the people who are taking care of the patient are not injured in any way.

For those psychiatric emergencies, like I said, we treat them very carefully. We may need to use antipsychotic medications to calm the patient down. We may need to use intramuscular or intravenous medications to bring the patient's behavior under control, but that is only in less than 10% of symptoms.

So, the emergent behaviors are psychiatric emergencies. They are treated at the emergency room. The patient may need medications like antipsychotics and may need intramuscular or intravenous formulation. We may need to use soft restraints to prevent injury to the patients and their caregivers, and the patient may need involuntary hospitalization for further management.

That's 10%. The 90% are the non-emergent behaviors, and we see them as psychobehavioral symptoms. That means that these are behaviors which are similar to common psychiatric disorders. If the patient presents with depressive symptoms, we use selective serotonin reuptake inhibitor (SSRI) antidepressants, serotonin–norepinephrine reuptake inhibitor (SNRI) antidepressants, bupropion, or mirtazapine to treat these behaviors.

If the patient presents with mood instability, we may use the anticonvulsant mood stabilizers or we may use antipsychotic mood stabilizers. If the patient is presenting with more anxiety symptoms, then SSRI/SNRI antidepressants, bupropion, or mirtazapine may be used.

Again, each patient will have their own individualized treatment plan, with nonpharmacologic management at the center, and then pharmacological management for behaviors that need more input or have not responded adequately to nonpharmacologic management strategy.

One size does not fit all. You need to monitor these patients very carefully. One of the questions that people ask me is, how often do you monitor these patients? It depends entirely on where the patient is being evaluated. If the patient is being evaluated in the outpatient clinic, every 3 to 4 weeks you can also have telephone contact with the patients and their family members.

If the patient is in an assisted living facility or nursing home, you can see them once or twice a week. If the patient is in the inpatient hospital, the patient is being evaluated continuously. So, again, one size does not fit all, and constant monitoring for both effects and adverse effects is required.

What metrics or patient-reported outcomes do you use to assess the effectiveness of your agitation-management strategy in Alzheimer disease?

Dr Tampi: We mainly look for clinical improvement. If we are using rating scales, we may look for improvement in symptoms.

Some of the rating scales we use are the Geriatric Depression Scale for depressive symptoms, or we may use the Patient Health Questionnaire-9 (PHQ-9). For anxiety symptoms, we look at the General Anxiety Disorder-7 (GAD-7). For the behavioral symptoms, we use the Pittsburgh Agitation Scale (PAS), and we monitor them depending upon how often we are seeing the patient.

We may also talk to the family members and have them rate their symptom improvement. You can use a 1 to 10 scale, which is simple, or a 1 to 100 scale, depending upon whether the patient is doing better or not and by how much. We, of course, monitor for physiological parameters, such as blood pressure and pulse rate to make sure that the patient is not having any hypotension, bradycardia, tachycardia, or hypertension.

We also monitor for physical symptoms. We monitor gait, we monitor balance, and we monitor weight so that the patient is either not gaining or losing too much weight. Again, we tailor to the kinds of symptoms the patient is presenting with, the equipment that we have available, and exactly where the patient is being monitored, whether it's in the home, the assisted living facility, the nursing home, or an inpatient unit.

The inpatient unit is for emergent behaviors, and they get more comprehensive management there because it's an acute care setting.

Can you share how you address safety and quality concerns when managing agitation in patients with Alzheimer disease, particularly those who are frail, have significant cognitive impairment, or are on complex medication regimens?

Dr Tampi: Another excellent question. Remember, this is a team effort. It is not an individual effort. My work is only half done if only I’m doing the work. I have to use a team of people to help me with that. The family members and the patient are central to that team. We involve everybody.

I always say that safety is not one person's responsibility; it is everybody's responsibility. Education, like I said before, is the nonpharmacologic management that has been shown to be the best in the management of agitation. We do educate patients, we educate caregivers, and we educate providers so that they are all participating in the care of the individual.

Remember that older adults are very sensitive to medications. Older adults can have significantly more adverse effects with medication. You have to have that individualized treatment plan, and everybody has to buy in to why the treatment plan is being implemented. There should be clear goals of what should improve and what we are going to be monitoring.

A patient-centric approach with a team effort is what is required to manage the frail elderly when we are seeing agitation with dementia.

What advice do you have for long-term care clinicians and medical directors looking to improve recognition, documentation, and management of agitation in Alzheimer disease within their facilities?

Dr Tampi: I will repeat again: This is a team effort. This is not an individual effort. Medical directors are not alone in the care of older adults with dementia with behavioral disturbances. They should use their team, they should use the family members, and they should use whatever skills that the patient has to maximize outcomes.

They have to have a clear plan for each patient to monitor for effects and adverse effects if the patient is being monitored for medication. The team should meet regularly to update these treatment plans. When you're taking care of the patient, you sometimes forget that the team members also need support, so make sure you're talking to the patient's family members and ensure that they are doing well.

If the patient is in an assisted living facility, a nursing home, or an inpatient unit, the professional who's taking care of the patient may also need the care because it takes a village to take care of an older adult, especially with dementia and behavioral disturbances. While caring for the patient, also care for the caregivers, because burnout is a big issue. Caregiving is long, caregiving is tough, and outcomes for caregivers are not good. Medical directors should also pay attention to the wellness of the caregivers.

So, the important points to remember are: This is a team effort. Nonpharmacologic management is a cornerstone. Medications should only be used for behaviors that are not responsive or not adequately responsive to medications. You should have guidelines for what medications you're going to use and how you're going to use them. Constant monitoring for effects and adverse effects [is essential]. Take care of the patient—it’s a team effort—and take care of the caregivers. These are a few points that I would like to emphasize for the medical directors who are caring for these individuals.