Diagnosing Agitation in Alzheimer’s Disease

The differential diagnosis in a patient with agitation and Alzheimer’s disease includes infection, dehydration, pain, and certain medications (eg, antihistamines, anticholinergics, opioids, corticosteroids, and sedatives). In addition to recognizing the pathophysiologic basis of agitation in Alzheimer’s disease, it is important to consider potential environmental factors, including a lack of predictable routines, overstimulation, understimulation, cognitive changes, emotional changes, and existing mood disorders.^1,2

An actionable framework for symptom assessment and management is the “DICE” algorithm (ie, Describe, Investigate, Create, Evaluate). It begins with a description of the behavior from the caregiver in the context of a social and physical environment. Then comes an investigation of potential contributors to the behavior, including medication-related adverse events, pain, functional limitations, comorbidities, poor sleep hygiene, and sensory changes. Next is the creation of a multidisciplinary plan to address the agitation, which may include caregiver education, enhanced communication with the patient, meaningful activities to occupy the patient, simplifying complex everyday tasks, ensuring environmental safety, and adjusting the level of patient stimulation. Finally, the provider must regularly evaluate the efficacy of the approaches and consider if medication is warranted.²