For families of residents
“Agitated” is a description of what someone looks like. It is not a diagnosis, and it is not a reason on its own. In a person who has lost the ability to say what is wrong, behavior is the remaining channel.
Before you read on
Never stop or change a prescribed medication without speaking to your own prescriber. Several of the classes described on this site rebound, or cause a withdrawal syndrome, when they are stopped abruptly, and some have to be reduced gradually over weeks or months under supervision. Nothing here is advice about your own medication, and nothing here is a reason to change anything on your own.
What it usually turns out to be
The ordinary answers come first, and they come first for a reason: they are common, they are fixable, and missing one of them means a person is medicated for a full bladder.
- Pain — the most commonly missed, in exactly the people least able to report it.
- Needing the bathroom, which is why bathroom breaks appear on lists of approaches to behavior.
- Hunger, thirst, cold, or an uncomfortable chair.
- An infection, constipation, or dehydration.
- A medicine started recently.
- Too much going on — noise, a television, a busy corridor, an environment that gives no clue what time it is.
- Boredom, or an activity pitched too high or too low.
The pain point, which is not a hunch
It has been tested. A cluster randomized trial in 60 units across 18 nursing homes enrolled 352 residents with moderate to severe dementia and clinically significant behavioral disturbance. Half received a systematic stepwise pain-treatment protocol — starting with ordinary paracetamol for most participants — for eight weeks.
Agitation fell by an average of 17% compared with usual care, and the overall severity of neuropsychiatric symptoms improved as well. Then the pain treatment was withdrawn, and over the following four weeks the agitation scores went back up.
At the start of that trial, well over half the residents in both groups had clinically relevant pain. Treating it changed their behavior. Nobody had asked, because they could not say.
Why “she is just agitated” should prompt a question
Because the alternative to asking is usually a sedating medicine, and a sedating medicine makes the underlying cause harder to find. If the cause was pain, the person is now in pain and sedated. If it was a full bladder, they are now uncomfortable and sedated. And the sedation itself will be read, a few weeks later, as decline.
New confusion is different from gradual change
This distinction is worth knowing because it changes what should happen next.
| Delirium | Dementia progressing |
|---|---|
| Comes on over hours or days | Changes over months |
| Fluctuates through the day — better in the morning, worse in the evening | Does not fluctuate that way |
| Is caused by something: infection, dehydration, constipation, pain, urinary retention, a medicine | Is the underlying condition |
| Often reversible if the cause is found | Not reversible |
If a change came on quickly or comes and goes through the day, that pattern is worth reporting in those words. Medicines with anticholinergic effects and sedatives are both associated with delirium in older adults — in one study of 278 hospital patients aged 65 and over, an increase in delirium severity was linked to anticholinergic exposure the previous day.
One caution in the other direction: new confusion is a reason to assess, and it is not on its own a reason to test urine and start an antibiotic. A large share of long-term care residents have bacteria in the urine without an infection, and treating that finding adds a medicine without addressing what actually changed.
What you can supply that nobody else can
The guidance on assessing behavior explicitly asks for family input on past triggers and on what has worked before. You know that she worked nights for thirty years and has never settled at ten o’clock. You know he was a teacher and calms down when given something to organize. You know she has never in her life liked being approached from behind.
None of that is in any record, and all of it changes what the afternoon looks like.
What helps, in the evidence
A network meta-analysis of 163 randomized studies covering 23,143 people with dementia found that several non-drug approaches outperformed usual care for aggression and agitation — massage and touch therapy, music combined with massage and touch, and multidisciplinary care — and concluded that non-pharmacologic interventions “seemed to be more efficacious than pharmacologic interventions.”
Music on its own is more modest than it is often described. The 2025 Cochrane review of music-based therapeutic interventions found that they probably improve depressive symptoms slightly and may improve overall behavioral problems — but probably do not reduce agitation or aggression, a null finding that has been stable across three successive versions of the review. Music matched to someone’s own history is a good thing that reliably changes the next twenty minutes for many people. It is not a treatment for dementia, and the honest version is more useful to you than the enthusiastic one.
Common questions
Should my mother be on a medicine for agitation?
Sometimes yes — the guidelines reserve antipsychotics for symptoms that are severe, dangerous, or causing significant distress, after non-drug approaches have been reviewed. That is a narrow indication and a real one. The questions worth asking are what the target symptom is, whether anyone recorded it, and when a reduction will be attempted. Antipsychotics in dementia.
He is quieter than he was. Is that the illness or the medication?
That is exactly the right question and it is the one most worth asking out loud, because the two look identical from outside. If the change followed a new or increased medicine, say so with dates. Sedation read as decline is the most consequential error in this whole subject. How a list gets long.
References
- Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ. 2011;343:d4065. PMID 21765198 · DOI 10.1136/bmj.d4065.
- Watt JA, Goodarzi Z, Veroniki AA, et al. Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis. Annals of Internal Medicine. 2019;171(9):633–642. PMID 31610547 · DOI 10.7326/M19-0993.
- van der Steen JT, van der Wouden JC, Methley AM, Smaling HJA, Vink AC, Bruinsma MS. Music-based therapeutic interventions for people with dementia. Cochrane Database of Systematic Reviews. 2025;3(3):CD003477. PMID 40049590 · DOI 10.1002/14651858.CD003477.pub5.
- Han L, McCusker J, Cole M, Abrahamowicz M, Primeau F, Elie M. Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Archives of Internal Medicine. 2001;161(8):1099–1105. PMID 11322844 · DOI 10.1001/archinte.161.8.1099.
- Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age and Ageing. 2011;40(1):23–29. PMID 21068014 · DOI 10.1093/ageing/afq140.
- Kales HC, Gitlin LN, Lyketsos CG; Detroit Expert Panel. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society. 2014;62(4):762–769. PMID 24635665 · DOI 10.1111/jgs.12730.
- Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. The American Journal of Psychiatry. 2016;173(5):543–546. PMID 27133416 · DOI 10.1176/appi.ajp.2015.173501.
Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.
Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.