Agitation, aggression, irritability, and hyperactivity are all commonly occurring symptoms in patients with dementia. These symptoms are associated with distress and negative health outcomes for both dementia patients and carers. Agitation, aggression, irritability, and hyperactivity may develop at any stage of dementia and across dementia subtypes. Therefore, the index of suspicion should be high for medical doctors and other professionals, who are charged with the care of this patient group.
Research is somewhat hampered by differences with regard to, for example, definitions of agitation, aggression, irritability, and hyperactivity used across studies. Nevertheless, recent years have seen progress in the understanding of underlying mechanisms and advances in treatment. Several large studies have established the presence of serious adverse effects associated with long-term use of antipsychotics in elderly patients and patients with dementia and the lack of effect of treatment for many dementia patients treated with these compounds. Coupled with an increasing research interest in non-pharmacological interventions, a shift from antipsychotics to non-pharmacological treatment as first-line treatment has occurred. However, choice with regard to which non-pharmacological treatment to initiate remains difficult due to a relatively narrow evidence base. Needless to say, lack of evidence does not equate to lack of efficacy.
Diagnosis and treatment of agitation, aggression, irritability, and hyperactivity should focus on identifying underlying causes. Infection, pain, and other medical illnesses are often the cause of these symptoms and may be easily treated. Furthermore, delirium must always be excluded as the cause. In the chapter, we have outlined a stepwise diagnostic and treatment approach based on our own experience and the works of other authors. If underlying causes are not identified or are deemed treatable by non-pharmacological treatment, non-pharmacological treatment is the first-line treatment. In some instances, antipsychotic treatment is indicated, despite aforementioned risk of side effect. In cases of extreme agitation and aggression, immediate institution of antipsychotic may be warranted. In most cases, it will be possible to delay treatment in order to carry out diagnostic tests and a trial of non-pharmacological treatment. Other pharmacological treatment includes AChEI and memantine, which may have an effect on agitation and aggression, most convincingly on the emergence of these symptoms.
Further research should focus on definitions of behaviors in order to facilitate research into underlying neurobiological mechanisms of agitation, aggression, irritability, and hyperactivity. This may also enable drug development with regard to compounds developed specifically to address agitation, aggression, irritability, and hyperactivity. Development of new non-pharmacological treatment approaches is warranted. Already established approaches should be tested in further studies to widen the evidence base.