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Original Nomination

Draft Key Questions:
These questions were available for public comment from Dec. 26, 2013–Jan. 17, 2014

Nonpharmacologic Interventions for Agitation and Aggression in Dementia

Draft Key Questions

Question 1
What is the comparative effectiveness of general interventions in managing agitated and aggressive behaviors among dementia patients:
  1. in long-term care settings?
  2. among community-dwelling dementia patients?
  3. What are the comparative harms of general interventions in managing agitated and aggressive behaviors among dementia patients?
Question 2
What is the comparative effectiveness of targeted interventions in managing agitated and aggressive behaviors among dementia patients:
  1. in long-term care settings?
  2. among community-dwelling dementia patients?
  3. What are the comparative harms of targeted interventions in managing agitated and aggressive behaviors among dementia patients?
Question 3
General Comments

Draft Analytic Framework

Figure 1 is  the analytical framework describing the flow of dementia patients with agitation and aggression through exposure to interventions aimed at preventing and/or reducing the frequency and severity of these behaviors. Interventions can be general or targeted to specific behaviors. Interventions can have associated harms. Outcomes include clinically reductions in the frequency and severity of agitation and aggression in the dementia patient, reductions and improvements in quality of life  among patients, staff, and caregivers.


“Dementia” refers to impairments in cognitive and intellectual ability, memory, language, reasoning, and judgment to an extent interfering with everyday functioning. The prevalence of dementia in the US population is approximately 14 percent of those 70 and older.40 The five most common forms of dementia include Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, Parkinson’s dementia, and fronto-temporal dementia, accounting for 95 percent of all dementias.41 Dementia patients may have a mixed type of dementia.

Individuals with dementia often experience behavioral or psychological symptoms. These symptoms affect up to 90 percent of individuals with dementia at some stage.42 Symptoms can include depression, psychosis, aggression, agitation, anxiety, and wandering.42,43 Behavioral and psychological symptoms cause considerable patient and caregiver distress; are associated with accelerated functional and cognitive decline; and leading predictors of institutionalization.41 These symptoms also challenge staff in long-term care (LTC) facilities where an estimated 80 percent of the residents with dementia experience some degree of behavioral and psychological symptoms.

Theoretical frameworks proposed to explain the etiology of behahvioral disorders in dementia include biologic/genetic; behavioral; reduced stress threshold; and unmet needs.44 Etiology frameworks are not mutually exclusive and may be specific to individuals and behaviors.

Agitation and aggression are separate behaviors that are especially distressing to patients, caregivers, and LTC staff. Agitation involves ‘excessive motor activity with a feeling of inner tension and characterized by a cluster of related symptoms including anxiety and irritability, motor restlessness and abnormal vocalization, often associated with behaviors such as pacing, wandering, aggression, shouting and night time disturbance’.45 Aggression is described as overt harmful actions to other persons that are clearly not accidental.45 Aggressive behaviors can be physical or verbal. The management of these behaviors has historically relied on pharmacological approaches, namely antipsychotics. Antipsychotic medications have limited evidence for efficacy and high risk for adverse effects and their use is associated with reduced quality of life.46 Concerns about these issues has led to recommendations that non-pharmacologic interventions be first choice therapies for agitation and aggression.47

A wide variety of non-pharmacological interventions are used to manage behavioral symptoms in dementia patients. The theoretical framework(s) underpinning specific interventions determine the objective and rationale of the intervention.44 Interventions can be general strategies for managing behavioral symptoms or interventions that target patient-specific behaviors.48 Non-pharmacologic interventions can be categorized as sensory; structured activity; social contact; medical/nursing; environmental; behavior therapy; culture change, system change, and staff training; and combination therapies/complex algorithms.44 General approaches can be implemented, often at the setting level. Examples include staff/caregiver education and training, structured activities, and sensory interventions.48 Improvements in behavior and mood have been reported in studies of stimulation-oriented treatments such as recreational activities; therapies involving music, art, and pets; and other programs that increase the number of pleasurable activities.49 Certain environmental interventions, such as environmental design and enhanced environment,44 would also be considered general approaches. Targeted approaches are interventions directed at single behaviors (i.e., agitation).48 These approaches typically involve a comprehensive assessment of the behavior to identify triggers and devise a plan to address the behavior by modifying exposures to triggers or and/or offering stimulating environmental distractions.48

Evidence synthesis on the comparative effectiveness of general and targeted interventions specifically for agitated and aggressive behaviors would inform guidance on non-pharmacologic approaches effective in managing agitation and aggression and would potentially assist in reducing the use of antipsychotics; reducing the frequency and severity of aggressive and agitated behaviors; improving functioning; and improving levels of distress and quality of life among dementia patients, their caregivers, and LTC staff.



Individuals with dementia and symptoms of agitation and aggression.


  • KQ1: General interventions
    • Staff/caregiver training and education
    • Patient-centered care
    • Special care units
    • Environmental design
    • Structured activities
  • KQ2: Targeted interventions50
    • Specific Intervention care plans.
    • Social interaction engagement
    • Promotion of positive activities and exercise
    • Personalized activities
    • Specialist psychosocial interventions


  • Usual care
  • Other non-pharmacologic intervention
  • Pharmacologic intervention


  • Intermediate
    1. Antipsychotic use
  • Final Health
    1. Frequency and severity of agitated behaviors
    2. Frequency and severity of aggressive behaviors
    3. Patient distress, affect, functioning, quality of life
    4. Caregiver/staff distress, quality of life
  • Adverse effects of intervention(s)
    1. Increase in other difficult behaviors


Any duration of follow-up


LTC and Community


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