Non-Pharmacologic Strategies and the DICE Approach to Agitation

This episode, "Non-Pharmacologic Strategies and the DICE Approach to Agitation," features the panel building a non-pharmacologic and framework-driven approach to agitation before medication ever enters the picture.

This episode surveys the non-pharmacologic toolkit for agitation, including reducing environmental clutter, music and pet or animal therapy, therapeutic touch, avoiding overstimulation, and individualized behavioral plans in long-term care, assisted living, or the home. Caregiver education programs, consistent daily schedules, and good sleep hygiene round out the panel's list. On the pharmacologic side, two treatments are now FDA-approved specifically for agitation associated with Alzheimer's dementia, though off-label agents remain common in practice due to formulary and long-term-care restrictions despite carrying greater risk.

The panel walks through the DICE framework for structuring an assessment: Describe the behavior in detail, including who is involved, where it happens, and what has recently changed for the patient, such as a new roommate or a lost relationship; Investigate what has and has not helped; Create a patient- and caregiver-centered plan that accounts for available resources, including the cost and lack of accreditation for in-home help; and Evaluate the plan's effectiveness over time and adjust as needed. One panelist recalls a long-term care resident whose agitation resolved simply once he was moved away from a disliked roommate, with no medication required.

Food and snacks emerge as an underappreciated non-pharmacologic tool, since this population often eats and drinks too little; one panelist shares a personal story of grilled cheese sandwiches and candy bars easing a parent's agitation, while cautioning against caregivers overeating in solidarity. The episode closes on the amygdala, a primitive threat-detection center that goes into overdrive when memory loss makes the world feel unfamiliar, while the prefrontal cortex can no longer rationalize those danger signals, leaving patients simply trying to feel safe rather than intentionally difficult.

Our next episode, "The Shift From Off-Label Use to On-Label Agitation Therapy," turns to how the standard of care for Alzheimer's agitation is shifting away from off-label prescribing.