---

Author: Michelle Brown

When someone you love has dementia, behavioral changes can be among the most challenging aspects to manage. Agitation—manifesting as restlessness, pacing, aggression, or verbal outbursts—often emerges as the disease progresses, leaving family caregivers wondering when to adjust their approach and when to seek medical intervention.

Understanding the difference between typical dementia behaviors and those requiring professional attention can make all the difference in the quality of life for both the person with dementia and their caregivers. Let's explore the nuanced landscape of agitation in dementia and develop a clearer picture of when environmental adjustments might help and when it's time to call the doctor.

The Many Faces of Agitation

Agitation in dementia rarely looks the same from person to person. Some individuals become physically restless—pacing relentlessly, fidgeting with objects, or attempting to leave home. Others express their distress verbally through repeated questions, calling out, or even shouting. Physical aggression might appear in some cases, while others demonstrate resistance to necessary care.

These behaviors don't simply arise from the disease itself but often represent attempts to communicate unmet needs or discomforts when words fail. Think of agitation as the tip of an iceberg—what we see above the surface hints at much more happening below.

Martha, who cared for her husband with Alzheimer's for seven years, recalls, "Tom would suddenly start pacing and trying to leave the house around 4 PM almost every day. I eventually realized this was when the house got noisier as the grandkids came home from school next door. The increased stimulation was simply too much for him to process."

Common Triggers of Agitation

Before calling the doctor, it's worth investigating potential environmental or situational triggers that might be causing the agitation:

Physical discomfort: Often overlooked, physical pain or discomfort frequently drives agitation. Constipation, urinary tract infections, joint pain, poor-fitting dentures, or even something as simple as an itchy tag on clothing can trigger distress when the person cannot clearly communicate what's wrong.

Overstimulation: Many people with dementia become overwhelmed by environments with too much noise, activity, or visual stimulation. What seems like normal household bustle to others might feel chaotic and frightening to someone with impaired cognitive processing.

Disrupted routines: People with dementia often rely heavily on familiar routines to navigate their increasingly confusing world. Changes to daily patterns—even positive ones like visits from loved ones or special outings—can trigger anxiety and agitation.

Misinterpreted sensory input: As dementia progresses, the brain may misinterpret shadows, reflections, or background noise, creating frightening perceptions that can lead to agitated responses.

Boredom or loneliness: Like all humans, people with dementia need meaningful engagement and connection. Without appropriate stimulation, boredom and isolation can manifest as restlessness or repetitive behaviors.

Environmental Adjustments Worth Trying

Before assuming medication changes are needed, consider these environmental approaches that often reduce agitation:

Simplify the environment: Remove clutter, reduce noise (turn off the TV when not being actively watched), and create clear visual pathways through living spaces.

Establish consistent routines: Regular meal times, sleep schedules, and activity patterns provide reassuring predictability.

Use calming sensory experiences: Soft music that the person enjoys, gentle touch like hand massage, or time outdoors in nature can soothe an agitated nervous system.

Validate feelings: Rather than contradicting or correcting, acknowledge the emotional reality. "You seem worried today. I'm here with you, and you're safe" often works better than "There's nothing to worry about."

Adjust communication: Use simple, direct language, maintain a calm tone, and reduce questions that might tax cognitive abilities.

Bob, whose mother has vascular dementia, shares, "We noticed Mom became much more agitated in the evenings. Our doctor suggested we create a 'sunset routine' with dimmer lighting, calming music, and a warm drink. It didn't eliminate all her sundowning behaviors, but it reduced them significantly."

When It's Time to Call the Doctor

While environmental approaches should usually be the first line of response, certain situations warrant medical attention. Contact your loved one's physician when:

• Agitation develops suddenly: A rapid change in behavior, especially when accompanied by confusion, fever, or changes in urination, might indicate an infection or other acute medical condition requiring prompt treatment.
• Behavior creates safety risks: When agitation leads to wandering in unsafe conditions, physical aggression that might harm the person or others, or refusal of essential care like eating or taking critical medications.
• Environmental approaches aren't helping: If you've consistently tried environmental modifications with little improvement over several weeks.
• Symptoms significantly impact quality of life: When agitation regularly prevents sleep, meals, or participation in previously enjoyed activities.
• Caregiver burnout looms: Sometimes the most important reason to seek medical help is to prevent caregiver exhaustion, which ultimately compromises care for everyone involved.

What to Expect When You Call the Doctor

When you decide medical input is needed, prepare for your appointment by:

Documenting patterns: Note when agitation occurs, how long it lasts, potential triggers, and what (if anything) seems to help. Specific examples are more helpful than general statements.

Listing all medications: Include over-the-counter products, supplements, and any recent changes.

Being honest about caregiver challenges: Physicians need an accurate picture of how behaviors affect both the person with dementia and their caregivers to make appropriate recommendations.

The doctor might suggest:

Medical evaluation: To rule out pain, infection, medication side effects, or other treatable conditions contributing to agitation.

Medication adjustments: This might include adding medications specifically for agitation, adjusting existing dementia medications, or discontinuing medications that could be contributing to the problem.

Referral to specialists: Such as a geriatric psychiatrist with expertise in dementia-related behaviors, or occupational therapists who can suggest specific environmental modifications.

Medication Considerations

When medications become necessary, they generally fall into several categories:

• Dementia-specific medications: Sometimes adjusting the timing or dosage of cholinesterase inhibitors or memantine can help manage behavioral symptoms.
• Antidepressants: Particularly effective when depression or anxiety contributes to agitation.
• Antipsychotics: Used cautiously and typically for shorter durations due to increased risks in older adults with dementia, but sometimes necessary for severe agitation.
• Mood stabilizers: May help manage aggressive behaviors in some cases.

It's important to understand that all medications carry potential risks and benefits. The decision to use medication should involve weighing these factors carefully, with the goal of improving quality of life while minimizing side effects.

Finding Balance in Dementia Care

Caring for someone with dementia requires an ongoing balance between acceptance and intervention. Some behavioral changes are simply part of the disease progression and respond best to adaptation and compassionate care. Others signal treatable medical issues or can be significantly improved with appropriate medication adjustments.

Janet, who coordinates a dementia caregiver support group, notes, "The most successful caregivers I know have developed good instincts about when to adapt and when to seek help. They've learned to be flexible while still advocating for medical attention when truly needed."

Remember that the goal isn't to eliminate all challenging behaviors—this may not be possible—but rather to maximize comfort, safety, and quality of life for both the person with dementia and those who provide their care.

By combining thoughtful environmental adjustments with appropriate medical care, families can navigate the complex territory of dementia-related agitation with greater confidence and effectiveness.