Clinical Question

What is the best approach to agitated patients with dementia?

Bottom Line

Nonpharmacologic approaches to agitation or aggression in patients with dementia are more effective than medication (e.g., haloperidol). Outdoor activities, multidisciplinary care, and massage and touch therapy with or without music are all effective. (Level of Evidence = 1a)

Synopsis

The authors searched five databases, including Cochrane CENTRAL and bibliographies of retrieved studies, identifying 163 randomized controlled studies of 23,143 patients that compared interventions for treating aggression and agitation in adults with dementia. Two investigators independently selected, abstracted, and evaluated the studies. Almost one-half of the studies were categorized as being at high risk of bias, mostly because of missing outcome data. Because not every intervention is directly compared with one another, the authors performed a network analysis, which allows indirect comparisons based on a common comparator. Typical antipsychotics provided no additional benefit compared with modifying instrumental activities of daily living (which is not more effective than usual care). Cannabinoids and dextromethorphan/quinidine (Nuedexta) were moderately more effective than instrumental activity of daily living modification. Outdoor activity, multidisciplinary care, and massage and touch therapy, with or without music, were effective in producing a large reduction in aggression and agitation.

Study design: Systematic review

Funding source: Government

Setting: Various (meta-analysis)

Reference: Watt JA, Goodarzi Z, Veroniki AA, 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(9):633–642.

Editor's Note: Dr. Shaughnessy is an assistant medical editor for AFP.