Non-pharmacological management of the agitated older individual

Scale and rationale. Agitation and aggressive behaviours will be seen at some point in almost all individuals with dementia, and behavioural and psychological symptoms of dementia are the commonest psychiatric problem in nursing homes. Non-drug management is first-line because no medication is FDA-approved for treating the neuropsychiatric symptoms of dementia, and all antipsychotics carry a boxed warning of increased stroke and mortality in this population.

Step 1 — search for and treat the medical cause. A medical workup often identifies one or more causes. Look for pain (the single most important and most missed), infection, especially urinary tract infection, dehydration, constipation and urinary retention, hypoxia, hypoglycaemia, electrolyte disturbance, delirium, sensory deprivation, and drug effects — anticholinergic medications, benzodiazepines, opioids, steroids and dopamine agonists. Treating pain alone significantly reduces agitation in nursing-home residents (Husebø cluster RCT).

Step 2 — identify the trigger. Environmental triggers (excessive noise, poor lighting, clutter, overheating, unfamiliar surroundings, over- or under-stimulation); psychosocial triggers (boredom, loneliness, loss of routine); and interpersonal triggers (a counter-therapeutic approach by family or professional carers — rushing, confrontation, arguing, task-focused care). Once these modifiable causes are addressed, the behaviour often improves sufficiently that no further intervention is needed.

Step 3 — the structured frameworks. DICE — Describe the behaviour, Investigate causes, Create a plan, Evaluate the outcome. ABC analysis — Antecedent, Behaviour, Consequence, recorded in a behaviour diary over several days to reveal the pattern. TREA — Treatment Routes for Exploring Agitation, matching the intervention to the unmet need behind the behaviour. Multiple sources of information may be needed in long-term care, including video recordings of the behaviour.

Step 4 — specific evidence-based interventions. Person-centred, individually tailored activity based on the person's life history and preferences; music therapy; massage and therapeutic touch; animal-assisted therapy; multisensory stimulation (Snoezelen); bright light therapy and sleep-wake regulation for sundowning; exercise and outdoor activity; reminiscence therapy; doll and simulated-presence therapy; and aromatherapy. Network meta-analytic evidence ranks massage therapy, animal-assisted intervention and personally tailored intervention as producing the most substantial reductions in agitation.

Step 5 — communication, environment and staff. Approach from the front, at eye level, one carer at a time; speak slowly with short simple sentences, one instruction at a time; do not argue, correct or confront — validate the emotion and redirect; offer choice and allow time. Modify the environment — consistent daily routine, familiar objects, adequate lighting, reduced noise, safe wandering space, visible clocks and calendars. Education and training of all healthcare providers working in long-term care homes is key, together with carer support to prevent burnout. Reserve antipsychotics for severe, distressing or dangerous behaviour that persists after these measures, at the lowest dose, with a defined review and withdrawal date.

International Psychogeriatric Association consensus definition of agitation in cognitive disorders and the 2023–2025 evidence base. The IPA provisional consensus definition requires excessive motor activity, verbal aggression or physical aggression causing excess distress or disability, beyond that attributable to another disorder — giving a standard outcome definition for trials. Recent network meta-analyses and umbrella reviews (through 2025) confirm that personally tailored activity, massage and touch therapy, animal-assisted intervention, music-based therapy and exercise outperform usual care, and that non-pharmacological interventions should be tried first and continued even when a drug is added. Where a drug is unavoidable, brexpiprazole (FDA-approved May 2023) is now the only agent licensed for agitation in Alzheimer's dementia, but it retains the class mortality boxed warning.