FAQ

Frequently Asked Questions About Agitation in Alzheimer Disease From Caregivers and Clinicians

Miranda Manier, BA

Agitation is a common yet complex symptom of Alzheimer disease. It can appear as physical or verbal aggression, motoric restlessness, disinhibition, or resistance to care—and it often signals that something is wrong, whether physically, emotionally, or environmentally. This FAQ addresses common questions about agitation from both caregivers and clinicians, offering practical strategies and clinical insights for managing one of the most challenging aspects of dementia care.

Questions from Caregivers and Loved Ones

What is agitation in Alzheimer disease?

Agitation refers to a group of behaviors that include restlessness, pacing, shouting, repetitive actions, resistance to care, and sometimes physical or verbal aggression. These behaviors often signal distress in someone who can no longer express needs clearly due to Alzheimer-related brain changes.1,2

What are the signs of agitation?

Common signs includeirritability, shouting or cursing, impulsive or aggressive movements or frank combativeness. Caregivers may notice patients refusing meals, becoming highly upset, panicked or guarded. These behaviors can escalate quickly without clear explanation.2

Why do people with Alzheimer disease become agitated?

Agitation often results from unmet physical or emotional needs, confusion, or environmental stress. Common causes include:

  • Physical: pain or physical discomfort (e.g., from constipation) infection, medication effects
  • Psychological: Fear, panic, loneliness, boredom
  • Environmental: Excess noise, lights or other stimulation, change in routine or unfamiliar setting.3,4

Because people with Alzheimer disease struggle to communicate, behaviors like yelling or striking out may be their only way of expressing distress.

What is sundowning, and why does agitation increase in the evening?

Sundowning refers to increased confusion, anxiety, or aggression that occurs in the late afternoon or evening. It’s linked to changes in lighting, fatigue, and disruptions in the circadian rhythm. To reduce sundowning:

  • Keep rooms well-lit in the evening
  • Maintain a predictable daily routine
  • Avoid caffeine and stimulating activities late in the day.5

How can I calm someone with Alzheimer disease when they are agitated?

Use these steps:

  • Stay calm: Your tone and posture matter more than your words.
  • Validate feelings: Say things like, “I see you’re upset” or “You’re safe.”
  • Redirect gently: Offer a drink or snack, play music, or show a familiar photo or other object.
  • Change the environment: Reduce noise, adjust lighting, or move to a quieter space.2,4

Avoid arguing or correcting. Instead, respond to the emotion—not the words.

What is the best way to approach someone during agitation?

Approach slowly from the front, speak softly, and make eye contact. Avoid sudden movements. Offer simple choices (“Would you like to sit here or in the kitchen?”) and never raise your voice. If touch is welcomed, a gentle hand on the shoulder can provide reassurance. Always ensure safety first.2,6

How do I prevent agitation before it starts?

Agitation can often be prevented by:

  • Sticking to a consistent routine
  • Managing pain, hunger, and toileting needs
  • Reducing noise and clutter
  • Providing engaging and meaningful activities
  • Monitoring medications for side effects
  • Avoiding overwhelming tasks or choices4,7

Daily walks, music, and time with pets or loved ones can also reduce restlessness.

How do I figure out what’s triggering the behavior?

Keep a behavior log noting:

  • What happened before the episode or right afterwards?
  • Time of day and location
  • Who was present
  • What worked or didn’t

This can reveal patterns or functions of the behavior (e.g., agitation always happens before bathing as a way to avoid cold water, or at dinnertime in order to get help with eating) which in turn helps to informinterventions. Medical issues like infections or pain should be ruled out by a health care provider.3

What if they become violent or might hurt themselves?

  • Ensure safety: Remove sharp or breakable objects.
  • Give space: Don’t crowd the person; step back if needed and allow for them to freely move away
  • Don’t restrain unless absolutely necessary.
  • Use calming language: “You’re okay, I’m right here.”
  • Call for help if there’s serious risk.

Once the episode passes, speak with their health care provider about possible causes and treatments.6,8

Questions about treating agitation in Alzheimer disease

How prevalent is agitation in Alzheimer disease?

Agitation affects 30% to 50% of individuals with Alzheimer disease, and prevalence increases with disease progression. In institutional settings, rates can exceed 70%. It is one of the most common behavioral and psychological symptoms of dementia.9

When does agitation typically occur in the disease course?

Agitation most often emerges in the moderate to severe stages of Alzheimer disease but can occur earlier, especially when environmental stressors or acute medical issues are present. Behavioral symptoms tend to fluctuate and can worsen during hospitalizations or care transitions.9,10

What causes agitation from a physiological perspective?

Key contributors include:

  • Neurodegeneration in the frontal and temporal lobes
  • Dysregulation of serotonin, dopamine, and norepinephrine pathways
  • Comorbid medical conditions (pain, infection, constipation)
  • Medication side effects (e.g., anticholinergics, benzodiazepines)11

How long do episodes last, and are they persistent?

Agitation episodes can vary from minutes to hours. Some patients experience isolated flare-ups; others have chronic symptoms over months. Agitation may resolve spontaneously or with interventions. Persistent agitation warrants a re-evaluation of pain, delirium, and environmental factors.10

What are the evidence-based nonpharmacologic interventions?

First-line approaches include:

  • Behavioral management (e.g. identifying  and modulating disruptive behaviors)
  • Environmental modifications (noise/light reduction, a structured routine, etc.)
  • Activity programming (exercise, music therapy, pet therapy, aromatherapy) 4,7
  • Validation therapy and redirection
  • Pain management (e.g., physical therapy, massage)

Clinicians should help caregivers identify triggers and tailor nonpharmacologic strategies to the individual.

When should medications be considered?

Use medications only if:

  • Agitation poses a safety risk
  • Nonpharmacologic strategies fail or take too long
  • The behavior causes significant distress
  • Underlying psychiatric disorders (e.g, psychotic disorder, bipolar disorder)

Pharmacologic treatment is not appropriate for mild, non-disruptive agitation. Before prescribing, rule out delirium, infection, pain, and side effects from other medications.9,12

What is the role of brexpiprazole and other pharmacologic options?

As of 2023, brexpiprazole is the first FDA-approved medication for agitation associated with Alzheimer disease. It demonstrated efficacy in reducing agitation symptoms in two Phase 3 trials.12

Other options include:

  • Antipsychotics (e.g.off-label use of the following agents issupported by multiple trials: risperidone, olanzapine, quetiapine, aripiprazole)
  • Antidepressants (e.g., SSRIs and SNRIs may behelpful for agitation due to underlying anxiety or depression)
  • Benzodiazepines (for short-term and as-needed effects from agents such as lorazepam, alprazolam and clonazepam). Trazodone is a non-benzodiazepine medication often used in low doses in a similar manner as benzodiazepines
  • Other (limited data for prazosin, dronabinol, dextromephorpan + quinidine, dextromethorphan + buproprion, and others)

Use lowest effective dose, monitor for adverse effects, and reassess regularly. Antipsychotics carry a black box warning for increased mortality in elderly dementia patients and should be discontinued if not effective.12,13

What should be the clinician’s approach to caregiver support?

Clinicians should:

  • Educate caregivers on common triggers and de-escalation strategies
  • Encourage use of behavior logs to track behavioral frequency and patterns
  • Emphasize the importance of self-care
  • Support groups and individual counseling
  • Provide disease education at baseline and routine guidance as cognitive decline progresses

Referrals for the patient to physical/speech/occupational therapy, day programs, home health agencies, care managers and eventually palliative care can be valuable resources for caregivers.3,7

References

  1. National Institute on Aging. Coping with agitation and aggression in Alzheimer disease. Alzheimer’s Caregiving Tips. Updated 2024. Accessed July 31, 2025. https://www.nia.nih.gov/health/coping-agitation-and-aggression-alzheimers-disease
  2. Alzheimer’s Association. Anxiety and agitation. Updated 2024. Accessed July 31, 2025. https://www.alz.org/help-support/caregiving/stages-behaviors/anxiety-agitation
  3. Grossberg GT. Pearls for primary care: how to talk about agitation in Alzheimer disease with caregivers. Patient Care Online. December 2024. Accessed July 31, 2025. https://www.patientcareonline.com/view/pearls-for-primary-care-how-to-talk-about-agitation-in-alzheimer-disease-with-caregivers
  4. Carrarini C, Russo M, Dono F, et al. Agitation and dementia: prevention and treatment strategies in acute and chronic conditions. Front Neurol. 2021;12:644317. doi:10.3389/fneur.2021.644317
  5. Mayo Clinic. Sundowning: late-day confusion in dementia. Reviewed 2024. Accessed July 31, 2025. https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/sundowning/art-20048238
  6. Amedisys Hospice Care. What is terminal agitation? How hospice treats terminal restlessness. Updated 2022. Accessed July 31, 2025. https://www.amedisys.com/resources/hospice/what-is-terminal-agitation
  7. Leng M, Zhao Y, Wang Z. Comparative efficacy of non‑pharmacological interventions on agitation in people with dementia: a systematic review and Bayesian network meta‑analysis. Int J Nurs Stud. 2020;102:103489. doi:10.1016/j.ijnurstu.2019.103489
  8. Yunusa I, Rashid N, Demos GN, et al. Comparative outcomes of commonly used off-label atypical antipsychotics in dementia-related psychosis: a network meta-analysis. Adv Ther. 2022;39(5):2053–2068. doi:10.1007/s12325-022-02075-8
  9. Tampi RR, Tampi DJ, Balachandran S, Srinivasan S. Antipsychotic use in dementia: a systematic review of benefits and risks from meta‑analyses. Ther Adv Chronic Dis. 2016;7(5):229–245. doi:10.1177/2040622316658463
  10. Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. 2015;350:h369. doi:10.1136/bmj.h369
  11. Chen Y, Dang M, Zhang Z. Brain mechanisms underlying neuropsychiatric symptoms in Alzheimer’s disease: a systematic review of symptom-general and –specific lesion patterns. Mol Neurodegener. 2021;16:38. doi:10.1186/s13024-021-00456-1
  12. FDA approves first drug to treat agitation symptoms associated with dementia due to Alzheimer disease. News release. U.S. Food and Drug Administration; May 11, 2023. Accessed July 31, 2025. https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-treat-agitation-symptoms-associated-dementia-due-alzheimers-disease
  13. Porsteinsson AP, Drye LT, Pollock BG, et al. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. JAMA. 2014;311(7):682-691. doi:10.1001/jama.2014.93