Synopsis
Interpret distress and behaviour as communication, identify delirium and remediable clinical or environmental causes, deliver personalised psychosocial care, and restrict antipsychotics to NICE-defined severe distress or harm-risk situations.
- Agitation, aggression, calling out, wandering, resistance, apathy, sleep change, hallucinations, delusions and anxiety are descriptions requiring formulation, not diagnoses to suppress.
- Define exactly what happens, when, with whom and what precedes and follows it; vague labels such as challenging conceal useful triggers.
- NICE requires structured assessment for pain, delirium, inappropriate care and other clinical or environmental reasons before treatment for distress.
- Offer psychosocial and environmental interventions as initial and ongoing management, matched to communication, history, culture, sensory ability and preferences.
- Personalised activities should promote engagement, pleasure and interest for agitation or aggression rather than merely occupy time.
- Only offer an antipsychotic when the person risks harming themselves or others, or agitation, hallucinations or delusions cause severe distress.
- Discuss benefits and harms, use the lowest effective dose for the shortest possible time, reassess at least every six weeks and stop without clear ongoing benefit.
- Risperidone's UK licence is narrow: up to six weeks for persistent aggression in moderate-to-severe Alzheimer's disease after non-drug approaches and with harm risk.
- Do not offer valproate for agitation or aggression in dementia unless it is indicated for another condition.
- Continue psychosocial care during and after medication; sedation is not evidence that fear, pain, boredom or unmet need has resolved.
Key red flags
Hours-to-days fluctuation in attention or arousal is delirium superimposed on dementia until acute causes have been assessed and treated.
New focal neurology, seizure, head injury, severe headache, reduced consciousness or abnormal physiology needs an emergency medical pathway.
Pain, urinary retention, faecal impaction, dehydration, hunger, infection and medicine withdrawal can present primarily as distress or aggression.
Immediate risk of serious harm to the person or others requires a least-restrictive safety response while causes are investigated.
Rigidity, fever, dysphagia, marked sedation or autonomic instability after an antipsychotic requires urgent cessation and medical assessment.
Dementia with Lewy bodies or Parkinson's disease dementia increases the risk of severe antipsychotic sensitivity and motor deterioration.
Unexplained fear of a particular person, bruising, restraint, poor hygiene, malnutrition or financial control raises a safeguarding concern.
Investigation priorities
Record antecedents, observable behaviour, consequences, onset, fluctuation, frequency, severity and setting.
Management branches
Behaviour, perception, sleep or engagement changes acutely or becomes newly distressing.
- Assess physiology, delirium, pain, retention, constipation, injury, medicines and immediate least-restrictive safety needs.
- Describe antecedents, behaviour and consequences and ask the person and supporters about communication, routine and likely meaning.
- Treat clinical causes and implement personalised communication, environmental and activity measures with a named review point.