Differentiating Agitation from Depression, Anxiety, and Psychosis

This episode, "Differentiating Agitation From Depression, Anxiety, and Psychosis," features the panel working through how to tell agitation apart from its psychiatric look-alikes.

The panel turns first to how neurology approaches a patient with new agitation, cautioning against jumping straight to a target symptom without a fuller medical workup. A change in behavior should prompt evaluation for other neurological and psychiatric conditions, including urine, blood, and imaging studies, and screening for seizures. Attributing new agitation to dementia itself should be a diagnosis of exclusion, made only after other causes are ruled out. From a psychiatric standpoint, most agitation has an identifiable trigger, whether medical, environmental, or situational, and clinicians are urged to apply an ABC framework: antecedent, behavior, and consequence. Common medical culprits include pain and constipation, both frequently underreported since patients often cannot articulate them, along with rushed or inconsistent caregiving and cluttered or uncomfortable environments. One panelist recalls a patient whose sudden agitation turned out to be an unwitnessed, undiagnosed femur fracture, a reminder that unexplained behavior change deserves a careful medical look before it is labeled as dementia-related.

The discussion then turns to distinguishing agitation from co-occurring depression, anxiety, and psychosis. Agitation, per the IPA definition, represents a change from a patient's usual baseline lasting at least two weeks, or an especially pronounced change, marked by emotional disquiet triggered by an internal or external stimulus. Depression tends to bring a persistent, untriggered low mood, social withdrawal, and changes in sleep and appetite. Anxiety involves worry and rumination without agitation's physical activation. Psychosis usually emerges later in the disease and requires ruling out delirium, distinguished by hallucinations beyond ordinary confusion. On formal scales, the panel notes that instruments like the NPI and the 29-item CMAI are mainly used in clinical trials, while day-to-day practice more often relies on a simplified caregiver checklist and a severity rating tracking just two or three target behaviors over time.

Up next, in "Coordinating Care and Caregiver Burden in Agitation," the experts examine caregiver burden and the gaps in coordinating care across specialties.