Where Does a New Treatment Option Fit Within the Management of Agitation Associated With Alzheimer Disease?

Agitation is a common and clinically challenging symptom in patients with Alzheimer disease, often requiring a multidisciplinary approach that includes assessment for underlying medical, psychiatric, environmental, and caregiver-related factors. In this interview, Rajesh R. Tampi, MD, discusses how newly available pharmacologic options may influence treatment planning for patients with agitation associated with Alzheimer disease, when medications should be considered, and why nonpharmacologic management remains central to care. Dr. Tampi also highlights key monitoring considerations for clinicians in outpatient, assisted living, and long-term care settings, as well as the importance of supporting both caregivers and health care providers.

Additional Resources: Tampi RR. How I treat: agitation in Alzheimer disease. HMP Global Learning Network. Published January 5, 2026. Accessed June 16, 2026. https://www.hmpgloballearningnetwork.com/site/altc/videos/how-i-treat-agitation-alzheimer-disease 

Key Highlights

• Agitation is common in patients with Alzheimer disease and requires a thorough assessment of medical, psychiatric, environmental, biological, and caregiver-related factors before pharmacologic treatment is considered.
• Nonpharmacologic strategies, including caregiver education, staff training, redirection, music therapy, reminiscence therapy, pet therapy, and multimodal interventions, remain the cornerstone of treatment for agitation associated with Alzheimer disease.
• Newly approved medications may give clinicians additional treatment options, but Dr. Tampi emphasized that pharmacologic therapy should be used alongside nonpharmacologic management and monitored closely by a multidisciplinary care team.

Consultant360: How does a new FDA approval impact or change your typical treatment protocol for managing agitation in Alzheimer disease, if at all?

Rajesh R. Tampi, MD: Agitation is not an uncommon symptom in individuals with Alzheimer disease. About 36% to 78% of patients with Alzheimer disease will manifest agitation sometime during the course of the illness. Agitation usually happens in a more moderate to severe dementia stage of Alzheimer disease, but now the newer evidence is that agitation can happen anytime. So the question to ask is why does agitation happen in these individuals? And the reason is many. They can have environmental factors, they can have relationship factors, they can have biological factors.

So in patients who present with agitation and Alzheimer disease, medication is a part of the treatment but not the whole treatment plan. So you have to get a good history from the patient and from people who are taking care of the patient. You have to do a good mental status examination to rule out whether they have many comorbid psychiatry conditions. You have to do lab work including urine drug screens. You may need neuroimaging studies of the brain. If there are vascular changes, you may need neuropsychological testing if you want to understand the etiology for whether this patient really has Alzheimer disease versus a mixed type of dementia versus other types of dementias. And then you decide on a treatment plan in conjunction with the patient and the caregivers.

Non-pharmacological managements, that includes training of staff, training of caregivers, reminiscence therapy, PET therapy, music therapy, multimodal interventions, redirection for agitated behaviors are the cornerstone of treatment of agitation. Medications are only used when the non-pharmacological managements are either not effective or partially effective. So in that situation, you look at medications. Brexpiprazole or Rexulti is the only other medication in addition to Auvelity, which is a combination of dextromethorphan and bupropion available in the market. So we now have two medications of different mechanisms of actions being available for the treatment of agitation in Alzheimer disease.

So it's a very specific indication for the two medications. And Auvelity is a new drug that was just FDA approved for agitation and Alzheimer disease. So how does management change? It changes in the sense that we'll have one additional medication that we can use. The good part with Auvelity is that it does not have the boxed warning for death. So because it's not an antipsychotic, there is no antipsychotic in it. It is dextromethorphan and then bupropion, bupropion as an antidepressant. Dextromethorphan is an NMDA antagonist, which improves a neurotransmission in the brain of individuals with Alzheimer disease. So we have a medication with a different indication of a different mechanism of action for a treatment of agitation in Alzheimer disease.

So where does that leave us? Now we have two medications, but the basic management is still the same. Again, we will also not know which patients respond well to this medication and which patients do not have adequate response. So that only time will tell with new trials and met analysis of all the trials that have been done so far.

Consultant360: Are non-pharmacological treatment options still the priority in the management of agitation associated with Alzheimer disease?

Dr. Tampi: Yeah. So with the new medication for the indication of agitation on Alzheimer disease, that would be coming on top of the medication list that we would use. So if the non-pharmacological managements have not worked or have been not adequate in managing the symptoms, then what do you do? What I preferentially do in individuals with Alzheimer disease, I usually start them on a cholinesterase inhibitor like donepezil, rivastigmine, or galantamine. Again, they're all equally effective in slowing down the progression of the dementia. It's like turning back the clock about 6 to 18 months. If the patient progresses from mild to moderate disease, then you add memantine to the cholinesterase inhibitor. If that combination is not good with improving symptoms, then you need to start looking at medications and Auvelity would be the drug now I would think about given the fact that it has controlled trials.

I think there are four randomized controlled trials of this medication for agitation and Alzheimer disease and it also does not have box warnings. If Auvelity does not work for some reason at the maximally tolerated dose, it's a BID dosing or twice a day dosing at the maximum dose, it has only two dosing strategies and the higher dose if it's not effective, then we'll have to look at other medications. Then something like Brexpiprazole would come next, then we have to go down the algorithm of different medications. I would always combine medications with non-pharmacological management, basically because the evidence suggests that combining these treatments can have a synergistic or a better outcome than either the non-pharmacological management or pharmacological management alone.

Consultant360: What monitoring practice or metrics are most important when initiating or reassessing pharmacologic treatment for patients with agitation associated Alzheimer disease?

Dr. Tampi: Yeah, thank you for asking that question. So treatment of these individuals, the basic protocols remain the same. Like I said, good history, good mental status examination, focused physical examination, lab work, additional testing if needed, meet with the patient and their caregivers, decide on a treatment plan. Non-pharmacological management becomes a cornerstone medications if these are not sufficient enough. Remember, it really does take a village to take care of an older adult with Alzheimer's disease, dementia, and behavioral symptoms. So what you want to do is you want to have a team that takes care of this individual. In the outpatient is basically the geriatrician or the geriatric psychiatrist and the patient and their family members. If the patient is living in an assisted living facility, then it is additional people, the people who provide care there, the physicians who go there or nurse practitioners who provide the care there.

And then if it's the nursing home, same thing, but a little more intensity in terms of the care provided. So involve all of them. So there should be a multidisciplinary treatment planning for this individual. Remember to do the medical things first, rule out underlying medical conditions, whether it's a urinary tract infection, if the patient is in pain, the patient has constipation, treat those first. If the patient has a drug problem or a medication prescribed medication adverse effect, remove that next and then start prescribing medications, monitor them closely. How often depends upon where the patient is in the outpatient clinic, at least every 4 to 6 weeks, the assisted living facility every couple of weeks in the nursing home, maybe a little more often, maybe once a week or so, just get the information. But the providers should do all the good physician things, as I say, making sure that the blood pressure is controlled, the diabetes is controlled, the high cholesterol is controlled, the heart is well taken care of and there are no other medical issues because if you don't pay attention to those, the outcomes for individuals with dementias with agitation is not going to be good.

So you have to have the medical management, the psychosocial management, and then of course the management of psychiatric using psychotropic medications like Auvelity.

Consultant360: How does a new treatment option impact caregivers and care teams? What do they need to know?

Dr. Tampi: An excellent question. I don't think it changes very much for the caregivers and the care teams. I think having an additional medication really does help because just having on approved medication really gives us no room in terms of pharmacological management. So having another medication that is available really does reduce the burden to the prescribing providers a little bit. But like I said before, always do the assessments and treatment plans first because that's what's going to give you the best bang for the buck. If you're just going to be relying on medications, I think it's going to be a mistake. So good history, good treatment planning, non-pharmacological management and pharmacological management in addition, including ability, now it becomes among the top medications because of its efficacy and its fairly benign side effect profile from what I have seen.

Consultant360: Is there anything else you would like to add?

Dr. Tampi: No, I always end all my discussions among older adults with mental health disorders, including those individuals with dementia, it really does take a village to take care of these individuals. So this is not an individual effort, it is a group effort. And I want to thank all my colleagues who are seeing these individuals because as a geriatric psychiatrist, I only get to see about 30% of these individuals because majority of the care is actually being done in the community by other providers who are not possibly trained in geriatric psychiatry or geriatric mental health. So I want to thank all of them for their effort and I would recommend them to continue to remain invested in these patients, work with the families, continue to review the new guidelines and treatment protocols that are coming. And if somebody like me can be of benefit in educating and providing assistance, I'm always happy to do that because it truly does take a team effort to provide good care to these individuals.

And if you feel burnt out, you really need to ask for help. You talk about caregiver burnout, but provider burnout is also a significant issue in healthcare right now. So as a psychiatrist, that's my primary role is to take care of patients and also to take care of the team that is taking care of the patient.

©2026 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Consultant360 or HMP Global, their employees, and affiliates.