Agitation Associated with Dementia Due to Alzheimer’s Disease: How Common Is It, and How Does It Present?

Welcome back to another Psychiatric Times Peer Exchange series. In "Agitation Associated with Dementia Due to Alzheimer’s Disease: How Common Is It, and How Does It Present?," moderator Marwan Sabbagh, MD, FAAN, FANA is joined by Amita Patel, MD, CMD, MHA, CPE, Erin Crown, MHS, PA-C, Psych-CAQ, David Liporace, DO, and Laura Melaro, DNP, APRN, FNP-BC, PMHNP-BC to open the series on agitation associated with dementia due to Alzheimer's disease.

Agitation ranks among the most common neuropsychiatric symptoms of Alzheimer's disease, and it eventually touches nearly the entire population of patients over the course of the disease. Across all disease stages, roughly 76% of patients present with some form of agitation. A large electronic health record study found agitation present even in mild dementia, with rates climbing from about 56% in moderate disease to nearly 70% in severe disease. Long-term care settings show even higher rates, with agitation present in 80% to 90% of residents. Agitation tends to intensify in the late afternoon and evening, a pattern known as sundowning, or during stressful transitions such as a new environment or a change in caregiver.

The panel groups agitated behaviors into three broad categories. Verbally aggressive behaviors include shouting, yelling, persistent negativity, repetitive statements, and offensive sexual comments. Physically non-aggressive behaviors include pacing, wandering, dressing in layers, and disrobing. Physically aggressive behaviors include hitting, kicking, biting, throwing or pulling down objects, and spitting, which the panel notes can even pose an infection risk.

Beyond these more visible presentations, the panel highlights subtler, easily overlooked signs. Any behavior that departs from a patient's lifelong personality can signal agitation, whether that means uncharacteristic sexual advances, sudden negativity or anxiety, eating non-food items, or obsessive behaviors like repeated hand washing or toilet flushing that resist redirection. Rummaging and resulting clutter are especially disruptive, since patients with Alzheimer's tend to function best in tidy, low-stimulation environments, and the mess they create can itself trigger further agitation. Withdrawal and reduced communication can also be an early, quietly missed expression of agitation. The panel closes by calling agitation something of a misnomer, since it is a broad syndrome with many shapes, and that variability often confuses caregivers and delays treatment.

The next episode in this series, "Differentiating Agitation From Depression, Anxiety, and Psychosis," features the panel distinguishing agitation from depression, anxiety, and psychosis.