Nonpharmacologic Options for Agitation in Alzheimer Disease Should Always Come First: Expert Insights

"There is no doubt that the nonpharmacologic approaches [to agitation in Alzheimer's disease] should always be prioritized. They should always come first. And if the nonpharmacologic approaches have failed or are not working, then we begin to think about pharmacotherapy or other interventions."

George Grossberg, MD, professor and director of geriatric psychiatry in the department of psychiatry at Saint Louis University School of Medicine, in a recent interview with Patient Care,® described a range of effective nonpharmacologic approaches to avoid or reduce agitated behavior in a person with Alzheimer disease and was clear that use of medication should be reserved for situations where a patient is not responding to those options.

Gentle music, massage, therapeutic touch, conversation, pet therapy are several interventions or environmental settings Grossberg mentioned that have been shown effective as first-line "therapy" for physically or verbally agitated behavior.

In the short video above Grossberg, a geriatric psychiatrist, describes a vignette with a patient with advanced Alzheimer's disease who responded remarkably to simple touch and engaged conversation. The key, he said, is to know the patient and individualize the nonpharmacologic approach to their needs, their hobbies, their background, to help keep them comfortable.

The following transcript has been lightly edited for length and clarity.

Patient Care: Would you describe some nonpharmacologic interventions you’ve had experience with and how they can be used best?

George Grossberg, MD: Now, there are many other non-pharmacologic approaches that can be just as helpful. Creating a calming environment, using soothing music, or incorporating therapeutic touch can make a big difference. I recently attended an international meeting where Dr. Jessica Cohen-Mansfield—who developed the Cohen-Mansfield Agitation Inventory—shared video examples of patients with advanced dementia responding well to nondrug approaches.

One video showed a patient with advanced Alzheimer’s sitting in a wheelchair near the nurses’ station, repeatedly calling out for help. Dr. Mansfield’s assistant, a young woman, came over, introduced herself, held the patient’s hand, and engaged her in conversation. For the entire 10-15 minutes that the assistant was interacting with her—using gentle touch and conversation—the patient didn’t call out once. It’s a powerful example of how personal interaction can reduce agitation in dementia patients.

Patients without any structure or activities in their day, whether at home or in a extended care facility, are more likely to become agitated. Regular interpersonal interactions are incredibly effective. Other non-drug interventions include pet therapy—whether real or robotic pets—doll therapy, music, aromatherapy, therapeutic touch, and massage. The key is to know the patient well and tailor these approaches to their interests, hobbies, and history. This individualized approach keeps them more comfortable and less likely to be agitated.

Of course, we would like to see this approach happen more often. The challenge is that, whether at home or in a long-term care facility, caregivers may not always know these strategies, and facilities are often understaffed. It's difficult to provide this level of care 24/7. But non-pharmacologic approaches should always be the first line of treatment. Only if these fail should we consider medications or other interventions.

George T Grossberg, MD, is the Samuel W. Fordyce professor and director of geriatric psychiatry in the department of psychiatry at Saint Louis University School of Medicine. He is a past president of the American Association for Geriatric Psychiatry and of the International Psychogeriatric Association. Grossberg's research focus includes behavioral symptoms in Alzheimer disease and novel therapies for neurocognitive disorders.