This webinar helps physicians conduct a systematic evaluation for behavioral changes in persons with dementia. It offers approaches for developing a comprehensive care plan for disruptive behaviors. These methods incorporate caregiver education and non-pharmacologic interventions followed by pharmacologic management.

1. Assessment and Management of Disruptive
Behaviors in Persons with Dementia

2. Objectives
• Describe the occurrence and impact of dementia-related behaviors
• Construct a systematic evaluation for behavioral changes in
persons with dementia
• Develop a comprehensive care plan that incorporates caregiver
education and non-pharmacologic interventions followed by
pharmacologic management for disruptive behaviors

3. Alzheimer's Association. (2023). 2023 Alzheimer’s Disease Facts and Figures. Retrieved from https://www.alz.org/media/ Documents/alzheimers-facts-and-figures.pdf
Most Common Etiologies of Dementia
Cause Prevalence Pathophysiology
Alzheimer’s disease 60-80%
Amyloid plaques and
neurofibrillary tangles
Mixed pathologies >50%
More than one neuropathology,
more common oldest old
Cerebrovascular disease 5-10%
Blood vessels damaged,
brain tissue injured
Lewy Body disease 5% Alpha-synuclein protein
Frontal Lobar Degeneration 3%
Tau protein
Transactive response
DNA-binding protein (TDP-43)

4. Alzheimer's Association. (2023). 2023 Alzheimer’s Disease Facts and Figures. Retrieved from https://www.alz.org/media/ Documents/alzheimers-facts-and-figures.pdf
Epidemiology
• 2023 US Alzheimer’s estimate:
– 6.7 million people aged 65+
– 2/3 are women, ~ 1 in 3 women
develop dementia in their lifetime
• More than 1 in 9 persons over
the age of 65 have dementia
• 1 in 3 persons over the age of 65
dies with dementia
• Diagnosis of dementia cuts
one’s life expectancy in half
• Dementia is the fifth-leading
cause of death in persons
over 65
• Between 2000-2019, dementia-
related deaths increased 145%

5. Natural History of Dementia
ADL
Dependency
Death
Low
Time (Slow decline)
High
Hospice Eligible
FAST 7a plus
Disease-related complication
within the last several months
Disease-related
complications include,
but are not limited to:
• UTI
• Sepsis
• Febrile episode
• Delirium
• Pneumonia
• Hip fracture
• Eating difficulty
or dysphagia
• Dehydration
• Feeding tube

6. 78 y/o with rapidly progressive Alzheimer’s and
vascular dementia after sustaining a fall at home
with a hip fracture that was surgically repaired.
During the patient’s skilled stay, the patient
has become mostly WC and/or bedbound and
not participating in PT with both physical and
verbal agitation and aggression, especially
when trying to engage in activities or move
the patient. The agitation is new since the
hip fracture.
The psychiatrist diagnosed the patient with
depression and prescribed sertraline 50mg
followed by valproic acid 250mg BID due to
refractory symptoms.
The patient has been more lethargic but remains
agitated at times. Additional changes include
5% weight loss in 1 month due to a poor appetite,
functional decline with a PPS decrease from 80
to 40, and dependency in 3/6 ADLs from 1/6 prior
to the fall.
After completion of skilled care, the patient was
transitioned to long term care. The daughter
expresses guilt as she recognizes her mom
is upset and angry because she never wanted
to be in a nursing home.
Case

7. Delirium
Acute Onset and
Fluctuating Course
AND Inattention
plus either
Disorganized
Thinking
Altered LOC
DELIRIUM

8. Terminal Restlessness
THE USUAL ROAD
THE DIFFICULT
ROAD

9. Dementia Behaviors
Thought and Perceptual
Disturbances
• Delusions
• Paranoia
• Hallucination
Mood Disturbances
• Anxiety
• Depression
• Irritability
Activity Disturbance
• Agitation and/or aggression
• Wandering
• Purposeless hyperactivity
• Apathy
• Impulsivity
• Socially inappropriate behavior
• Sleep problems
• Repetitive behavior

10. Agitation/Aggression Definition
International Psychogeriatric Association convened a panel of experts with the goal
of establishing principles guiding the definition of agitation in elderly populations:
1. Occurring in patients with cognitive
impairment or a dementia syndrome;
2. Exhibiting behavior consistent with
emotional distress;
3. Manifesting excessive motor activity,
verbal aggression, or physical
aggression; and
4. Evidencing behaviors that cause
excess disability and are not
solely attributable to another
disorder (psychiatric, medical,
or substance-related)

11. Radue, et al. (2019). Neuropsychiatric symptoms in dementia. Handbook of Clinical Neurology, 167, 437-454.
Neuropsychiatric Symptoms (NPS) by Stage of Dementia
4.3%
11.2% 15.2%
44.3%
38.2%
13.3%
32.6%
30.3%
30.0%
31.4%
82.3%
56.0% 54.5%
25.7% 30.4%
Normal
cognition
Mild cognitive
impairment
Mild dementia Moderate
dementia
Severe
dementia
No symptoms 1-2 symptoms 3+ symptoms
7%
16%
17%
31%
32%
34%
36%
39%
39%
40%
42%
49%
0% 10% 20% 30% 40% 50% 60%
Euphoria
Hallucinations
Disinhibition
Delusions
Aberant motor behavior
Appetite disorder
Irrtability
Sleep Disorder
Anxiety
Aggression
Depression
Apathy
80-90% of patients will develop neuropsychiatric symptoms over the course of their illness
No FDA-Approved Treatment for Neuropsychiatric Symptoms in Dementia

12. Mitchell, et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine (361), 1529-1538.
Symptom Experience in Persons With Dementia in the
Last Year of Life
0
5
10
15
20
25
30
35
40
Dyspnea Pain Pressure ulcers Aspiration Agitation
Residents
With
Symptoms
(%)
Distressing Symptoms
Months Before Death (no. of residents alive during interval)
>9-12 (N=67) >6-9 (N=96) >3-6 (N=128) 0-3 (N=177)

13. Cummings J et al. Reduction and prevention of agitation in persons with neurocognitive disorders: An IPA consensus algorithm International Psychogeriatrics 2022:
DICE
International Psychogeriatric Association
D
Describe the
behavior
I
Investigate the underlying
contributors/causes
C
Create intervention:
non-pharmacologic and
pharmacologic
E
Evaluate
the interventions
effectiveness
I
Investigate behavior plus
precipitants, duration, frequency,
potential harm; Impact intervention
P
Plan intervention that reflects
patient features and setting; share
DM with patient/CG
A
Act multidisciplinary plan with
psychosocial interventions and
choose pharmacologic treatments
if needed

14. O’Gorman, et al. (2020). A framework for developing pharmacotherapy for agitation in Alzheimer’s disease:
recommendations of the ISCTM working group. The Journal of Prevention of Alzheimer's Disease, 7(4), 274-282.
Behavior Description
• Characterization
• Severity or quantification
• Temporal onset and course
Scale Measure
Cohen-Mansfield
Agitation Inventory
4 behavioral categories, 29 total items, caregiver response over last 2 weeks,
behavior frequency ranges from 1 to 7, higher scores more behaviors
Neuropsychiatric
Inventory
10 or 12 (sleep and appetite added) behaviors rated by frequency
(4 categories) severity (3 categories), caregiver distress (5 categories)
over a week, higher scores more behavioral burden
Behavioral pathology
in Alzheimer’s disease
7 behavioral categories containing 25 symptoms, each scored
on a 4-point severity scale ascertained by a caregiver
• Caregiver status
• Context of personal, family,
social, and medical history
• Associated circumstances,
including precipitants and
alleviating factors

15. Impact of Disruptive Behaviors in Dementia
Patient
• Increased morbidity (cognitive/
functional); lower quality of life
• Abuse and neglect
• Increased likelihood of
hospitalization with
a longer length of stay
• Nursing home placement
• Increased mortality
Caregiver
• Increased burden, stress,
exhaustion, and strain
• Sleep disturbances,
depression, and anxiety
• Lower quality of life
• Reduced income
from employment
• Increased mortality

16. Case (cont.)
Describe the behavior and rationale to treat:
• Agitation and aggression worse with
movement and activity, new after fall
• Verbal (yelling when trying to move or
interact) and physical (resistive to daily
care and strike out when try to move)
• Intermittent sleeping and agitation and
daughter reports a poor quality of life
• Unsteady on feet, not wanting
to move around much
• Decreased oral intake
• Potential risk to staff for
physical harm

17. Kales HC, Gitlin LN, Lyketosis CG. Assessment and Management of behavioral and psychological symptoms of dementia. BMJ 2015; h369
DICE
D
Describe the
behavior
I
Investigate the
underlying
contributors/
causes
C
Create intervention:
non-pharmacologic
and pharmacologic
E
Evaluate
the interventions
effectiveness

18. Ringman JM, Schneider L. (2019) Treatment Options for Agitation in Dementia. In Current Treatment Options Neurology (Vol 21, 30).
Contributors to Agitation and Restlessness
Contributor Causes Approach
Physical symptom Pain, SOB, constipation Opioid or laxative
Psychological symptom
Depression, anxiety, bipolar disorder,
delusions, hallucinations
SSRI, SNRI,
antipsychotic
Medical condition
Infection, COPD, HF, gout, hyperglycemia, electrolyte
abnormality, broken bone, constipation, insomnia
Treat condition
Unmet need Hunger, thirst, hot, cold, boredom Attend to need
Sensory impairment Poor vision/hearing Adaptive
Environment
Under/over stimulation, change in routine, life stressor,
pt-cg relationship
Modify
Toxicology
Anticholinergic drug, digitalis, benzodiazepine, withdrawal
syndrome (ETOH, opioid cannabis), steroids
Discontinue

19. Huesbo B, Ballard C, Sandvik R, et al.(2011) Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ Vol. 343.
Atee M, Morris T, Macfarlane S et al. (2021) Pain in Dementia: Prevalence and Association with Neuropsychiatric Behaviors. J Pain Symptom Manage Vol 61, p 1215-1226.
Contributors to Agitation and Restlessness
Step Treatment Study Treatment
1 APAP Maximum dose 3gm
2 Morphine 5mg Twice daily
3 Buprenorphine
5mcg patch, can
increase to 10mcg
4 Pregabalin
25mg up to
300mg daily

20. Case (cont.)
Investigate
• Additional PMH patient grimaces with movement
and braces on the side with the hip fracture
repair. The patient is not taking the as-needed
acetaminophen and has no other analgesic
ordered. Staff report the patient seems to
alternate between agitation and over-sedation
and is otherwise withdrawn. Appetite is poor
but has no apparent nausea or constipation.
Insomnia with difficulty falling asleep and
early morning awakenings.
• Patient’s other chronic medical conditions are well
controlled. The patient does not have altercations
with staff or her roommate unless trying to be moved.
Her daughter reports mom misses her dog and home.
Besides the sertraline and valproic acid, no changes
in medications.
• Physical exam: temporal wasting, hearing and
vision seem intact, pain behaviors as described
especially with ROM of repaired hip, and bloodwork
is unremarkable.
Considerations
• Pain from hip fracture repair
• Depression
• Loneliness
• Medication

21. DICE
D
Describe the
behavior
I
Investigate the
underlying
contributors/
causes
C
Create intervention:
non-pharmacologic
and pharmacologic
E
Evaluate
the interventions
effectiveness

22. Ayalon, et al. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric
symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188.
Dementia Behavior Models
• Person with dementia
– Unmet need: behavior as an
underlying need
– Agitation etiology culmination
from present abilities, level of
cognition and function, and
past/present interests with
physical, psychological,
social, and spiritual needs
• Caregiver
– Learning and behavioral (ABC)
– Antecedent to behavior behavior
consequence reinforces behavior
• Environment
– Environmental vulnerability and
reduced stress thresholds: a
mismatch between the setting and
the patient’s ability to deal with it

23. Watt JA et al. Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis. Ann Intern Med 2019;171:633-642.
Non-Pharmacologic: Persons With Dementia
Treatment Studies (N)
Network
Meta-analysis
Meta-analysis
Standardized Mean
Difference
CMAI Re-expressed
as mean difference
on CMAI
Massage and Touch 6 (385) -0.75 (-1.12,-0.38) -0.90 (-1.28,-0.518) -10.67
Multidisciplinary
Care Plan
4 (552) -0.50 (-0.99,-0.01) -0.44 (-1.0,0.12) -7.11
Music +
Massage/Touch
1 (34) -0.91 (-1.75,-0.07) -1.71 (-2.36,-1.05) -12.94
Recreational Therapy 8 (474) - 0.29 (-0.57,-0.01) -0.26 (-0.64,0.12) -4.12
Bold text indicates treatment efficacy across all types of agitation and/or aggression, clinically important difference 5.69
(aggression) and 7.11 (agitation)

24. Leng, et al. (2020). Comparative efficacy of non-pharmacological interventions on agitation in people with dementia:
A systematic review and Bayesian network meta-analysis. International Journal of Nursing Studies, 102, 103489.
Non-Pharmacologic: Persons With Dementia
Treatment Standardized Mean Difference
Massage −5.22 ( −8.21,−2.49)
Light Therapy −5.25 (−9.90,−0.61)
Music Therapy −3.61 (−7.29, −0.23)
Reminiscence Therapy −4.59 (−8.97 to −0.51)
Animal-Assisted Intervention −3.14 (−5.89 to −0.46)
Personally Tailored Intervention −2.98 (−5.18 to −0.85)
For network meta-analysis,
demonstrated the following
rank probability:
• Massage therapy - 1 (43%)
• Animal-assisted
intervention - 2 (16%)
• Personally tailored
intervention - 3 (18%)
• Pet robot intervention -
4 (11%)

25. Hughes, et al. (2017). Research on supportive approaches for family and other caregivers. Research summit on dementia care: Building evidence for services and supports.
Non-Pharmacologic: Caregiver Interventions
• Elements of caregiver support
–Education and skills training (conflict avoidance,
problem solving, support, environmental
modification ADL, and communication skills)
–Care coordination
–Counseling and support groups
–Respite and self-care
• Example Programs
–REACH II and REACH VA
–The Tailored Activity Program (TAP) -
Occupational Therapy and Skills2Care
–Savvy Caregiver
–New York University Caregiver Intervention
• A meta-analysis of 23 randomized clinical trials,
involving almost 3,300 community-dwelling
patients and their caregivers
– Significantly reduced behavioral symptoms
(effect size 0.34, p<0.01) and negative
caregiver reaction (effect size 0.15, p<0.006)
– Similar to antipsychotics for behavior and
cholinesterase inhibitors for memory
– Interventions with multiple components and
specific to the caregiver and person with
dementia with regular follow-up had
greatest success

26. Responses to Non-Pharmacologic Interventions
Greater Response
• Higher levels of cognitive function
• Fewer difficulties with ADLs
• Speech
• Communication
• Responsiveness
Less Response
• Staff barriers (refuse to participate)
• Patient in pain

27. Case (cont.)
Describe behavior and rationale
to treat
• Agitation and aggression worse
with movement and activities
• Risk to patient and staff
Investigate
• Pain
• Depression and anxiety
• Loneliness
• Medication
Create: Non-pharmacologic
• Initiate animal-assisted intervention
as patient misses her dog
• Recreational therapy tailored to
the patient’s needs
• Consider what additional services
hospice could offer
• Pain: APAP 1,000mg every 8 hours,
morphine 5mg prior to bathing and
at night and prn. Bowel regimen
• Medication: Wean off valproic
acid and optimize depression treatment

28. Dementia Behaviors and Pharmacologic Treatment
Helpful
• Psychosis
– Delusions
– Hallucinations
– Paranoia
• Depression, anxiety, and irritability
• Agitation and aggression
Not Helpful
• Day/night reversal
• Calling out
• Repetitive behaviors
• Apathy
• Resistive to care
• Wandering

29. Therapeutic Class Trial Side Effects
Trazodone + RTC Sedation, hypotension
SSRI (citalopram) + RCT Nausea, diarrhea, QTc inc >20mg daily
Antipsychotics + RCT Stroke, infection, seizure, QTc inc, DM, death
Lorazepam + RCT Sedation, falls, ataxia, agitation
Dextromethorphan/quinidine + RCT Falls, dizziness, diarrhea, UTIs
Carbamazepine
Valproic acid
- RCT
- RCT
Sedation, anemia, liver toxicity, sedation
NMDA antagonist - RCT/+obs Constipation, dizziness
ACheI - /+RCT/+obs Nausea, dizziness, weight loss
Cannabinoids - RCT Low dose used, oral form
Radue, et al. (2019). Neuropsychiatric symptoms in dementia. Handbook of Clinical Neurology, 167, 437-454.
Ringman, J. et al. (2019). Treatment options for agitation in dementia. Current Treatment Options in Neurology, 21(7), 1-14.
Pharmacologic Treatment of Agitation
Comparative Effectiveness, Sequential Administration, or Concomitant Use Data Scarce

30. Trazadone
• Several small randomized
controlled trials indicate benefit
– Cochrane review
inconclusive evidence
– Often used for “Sundowning”
• Dosing:
– 25-100mg BID-TID and q 2hrs
prn, maximum dose 300mg daily
(150mg in frail older adults)
• Adverse effects:
– Orthostasis, syncope,
hypotension, dizziness
– Priapism
– SIADH
– Somnolence
– QTc prolongation

31. Antonsdottir, et al. (2015). Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinion on Pharmacotherapy, 16(11), 1649-1656.
Dementia-Related Agitation and Citalopram
Neurobehavioral Rating Scale (NBRS) - Agitation Subscale
No. of participants
Citalopram 94 87 85 86
Placebo 92 84 84 81

32. Citalopram Considerations
• Starting dose 10mg, up to 40mg daily
• QTc prolongation, which is
dose-dependent above does
of 20mg
• Confusion increased at doses
of 30mg daily or higher
• Consider 2x daily dosing
– 10mg daily for 2 weeks
– 10mg 2x daily thereafter
• Other SSRI side effects
• Onset of action within a week
in one study

33. Antipsychotics
• Most-studied pharmacologic intervention
for dementia-related agitation
• Moderate efficacy across trials and
agents (18% respond above
placebo response)
– Typical antipsychotics
– Atypical antipsychotics
• Substantial side effects
• Black box warning: cerebrovascular
events and death (1% difference)
• Lowest dose possible for the
shortest duration feasible

34. Antipsychotics (cont.)
Antipsychotic Recommended Dose Formulations Frequency Characteristics
Risperidone 0.5-2.0mg Tab, liquid, IM 2x daily
Extrapyramidal
symptoms
Olanzapine 2.5-15mg tab Daily Wt gain, inc sugar
Quetaipine 25-400mg tab
3x daily
(unless ER)
Sedating, least
extrapyramidal
Aripiprazole 5-30mg Tab, liquid, IM Daily Less QT
Haloperidol 0.5-5mg
Tab, liquid,
IM, IV, sub q
2-4x daily
Chlorpromazine 10-200mg
Tab, liquid,
IV, rectal
2-3x daily Very sedating

35. Schneider, L. S., et al. (2008) Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. The New England Journal of Medicine; 355(15), 1525-1538.
CATIE-AD
Greatest benefits in persons demonstrating anger, aggression, and paranoia

36. Devanand, et al. (2012). Relapse risk after discontinuation of risperidone in Alzheimer's disease. New England Journal of Medicine, 367(16), 1497-1507.
Relapse Risk With Antipsychotic Discontinuation
Severe baseline symptoms at initiation, increases likelihood of worsening symptoms with discontinuation

37. Watt, et al. (2019). Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network meta-analysis. Annals of Internal Medicine, 171(9), 633-642.
Antipsychotic Summary
• Modest efficacy for treatment
of agitation and aggression
in dementia
• Studies usually short duration:
6 to 12 week
• Large placebo effect: 30%
or higher on average
• No difference in efficacy
between typical and
atypical antipsychotics
• Typical antipsychotics–greater side effects
– Somnolence, urinary tract infection, incontinence
– Extrapyramidal symptoms and abnormal
gait and falls
– Anticholinergic effects, postural hypotension,
prolonged QT
– Weight gain, diabetes, and metabolic syndrome
– Cognitive worsening; seizures
– Stroke (NNH 99) and death (NNH 47)

38. *Cholinesterase inhibitors: Nausea, vomiting, diarrhea, dizziness, and agitation
FDA-Approved Medications for Alzheimer’s Disease
Medication Severity Dose Side Effects
Donepezil (Aricept) Mild to severe 5-10mg; 23mg *Nightmares
Rivastigmine (Exelon) Mild to moderate
4.6 & 9.5mg
(13mg) patch
*Weight loss
Galantamine (Razadyne) Mild to moderate 8-24mg *
Memantine (Namenda XR) Moderate to severe 28mg QD
Constipation,
dizziness, HA
Rivastigmine improves apathy, anxiety, delusions, and hallucinations in LBD
All cholinesterase inhibitors may delay onset/reduce behavioral symptoms in Alzheimer’s/LBD

39. Benzodiazepines
• Binds to GABA receptor in CNS
• Anxiolytic, sedative, and hypnotic
effects (anterograde memory)
• Some evidence lorazepam and
alprazolam to reduce agitation
• Increased risk of adverse events
– Cognitive impairment/
confusion/delirium
– Falls
– Hip fracture
– Sedation
– Paradoxical agitation
Benzodiazepine Half-life Dosage range
Diazepam
20-50 hours
Over 100 OA
2-10mg
2-4x day
Lorazepam 12 hours
0.5-2mg
2-3x day
Alprazolam
16 hours
(9-27 range)
0.25-3mg
2-4x day
Clonazepam 30-40 hours
0.25-5mg
2-3x day

40. Pimavanserine
• 5-HT2A antagonist indicated for
hallucinations and delusions
associated with Parkinson’s disease
• Three trials for agitation or psychosis
in dementia, all of which were
essentially negative
• Black box warning for increased
mortality in dementia and is
associated with QT prolongation,
peripheral edema, and confusion

41. Cummings, et al. (2015) Effect of dextromethorphan-quinidine on agitation in persons with
Alzheimer’s disease dementia. A randomized clinical trial. JAMA vol 314(12), 1242-54.
Dextromethorphan-Quinidine for Dementia Agitation
in Alzheimer’s Disease
• FDA approved for the treatment
of pseudobulbar affect
• Modulates glutamate,
serotonin, and norepinephrine
• Only one randomized, controlled
trial to date for dementia
related agitation
• Side effects include
– Falls
– UTIs
– Diarrhea
– Dizziness
• QTc prolongation

42. Phenobarbital
• No data available
• Many clinicians, health systems,
and long-term care facilities
leverage its use
• 30 to 120mg TID and q2 prn
• Adverse Reactions
– Respiratory depression
– Stevens-Johnsons
– Anemia, TTP, and blood
dyscrasias
– Withdrawal symptoms with
abrupt withdrawal
– Lethargy and drowsiness
– Nausea, vomiting, and hepatitis

43. DICE
D
Describe the
behavior
I
Investigate the
underlying
contributors/
causes
C
Create intervention:
non-pharmacologic
and pharmacologic
E
Evaluate
the interventions
effectiveness

44. Describe behavior and
rationale to treat
• Agitation and aggression worse
with movement and activities
• Risk to patient and staff
Investigate
• Pain
• Depression and anxiety
• Loneliness
• Medication
Case (cont.)
Create
Contributors APAP 1,000mg
every 8 hours, morphine 5mg every
8 hours, plus bowel regimen; stop
sertraline and initiate citalopram
Non-pharmacologic Animal-assisted
intervention/recreational therapy
Pharmacologic Citalopram and
wean off valproic acid; trazadone
25mg as needed

45. Case (cont.)
Describe behavior and
rationale to treat
• Agitation and aggression worse
with movement and activities.
• Risk to patient and staff
Investigate
• Pain
• Depression and anxiety
• Loneliness
• Medication
Create
Contributors APAP 1,000mg
every 8 hours, morphine 5mg
every 8 hours plus bowel regiment;
Citalopram 10mg twice daily
Non-pharmacologic Animal assisted
intervention/recreational therapy
Pharmacologic Citalopram 10mg
twice daily, off valproic acid;
trazadone 50mg nightly and
able to discontinue as needed

46. Al Ghassani, et al. (2021). Agitation in people with dementia: A concept analysis. Nursing Forum, 56(4), 1015-1023).
Alzheimer's Association. (2023). 2023 Alzheimer’s Disease Facts and Figures. Retrieved from https://www.alz.org/
media/Documents/alzheimers-facts-and-figures.pdf
Antonsdottir, et al. (2015) Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinion on
Pharmacotherapy, vol 16(11), 1649-1656.
Gaugler, et al. (2021). Alzheimer’s Association. 2021 Alzheimer’s Disease Facts and Figures. Alzheimer’s Dementia:
Chicago, IL, USA, 17.
Atee et al. (2021) Pain in Dementia: Prevalence and Association with Neuropsychiatric Behaviors. Journal of Pain
Symptom Manage Vol 61, p 1215-1226.
Ayalon, et al. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric
symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188.
Ballard, C. et al. (2009). Management of agitation and aggression associated with Alzheimer disease. Nature Reviews
Neurology, 5(5), 245-255.
Cohen-Mansfield, et al. (2014). Predictors of the impact of nonpharmacologic interventions for agitation in nursing
home residents with advanced dementia. The Journal of Clinical Psychiatry, 75(7), 15076.
Cummings, J. (2015). Effect of dextromethorphan-quinidine on agitation in patients with Alzheimer disease dementia:
a randomized clinical trial. JAMA, 314(12), 1242-1254.
References

47. Devanand, et al. (2012). Relapse risk after discontinuation of risperidone in Alzheimer's disease. New England Journal of
Medicine, 367(16), 1497-1507.
Husebo, et al. (2011). Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia:
cluster randomised clinical trial. BMJ, 343.
Hughes, et al. (2017). Research on supportive approaches for family and other caregivers. Research summit on dementia care:
Building evidence for services and supports.
Leng, et al. (2020). Comparative efficacy of non-pharmacological interventions on agitation in people with dementia: A systematic
review and Bayesian network meta-analysis. International Journal of Nursing Studies, 102, 103489.
Mitchell, et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine (361), 1529-1538.
O’Gorman, et al. (2020). A framework for developing pharmacotherapy for agitation in Alzheimer’s disease: recommendations
of the ISCTM working group. The Journal of Prevention of Alzheimer's Disease, 7(4), 274-282.
Radue, et al. (2019). Neuropsychiatric symptoms in dementia. Handbook of Clinical Neurology, 167, 437-454.
Ringman, J. et al. (2019). Treatment options for agitation in dementia. Current Treatment Options in Neurology, 21(7), 1-14.
Schneider, L. S., et al. (2008) Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. The New England
Journal of Medicine; 355(15), 1525-1538.
Watt, et al. (2019). Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic
review and network meta-analysis. Annals of Internal Medicine, 171(9), 633-642.
References