A practical guide for care homes on understanding agitation in dementia, including distress, unmet need, pain, overstimulation and formulation-led care planning.
This article provides general education for care providers. It does not replace assessment by the resident’s GP, community services, safeguarding team, mental capacity decision-maker, prescriber or emergency services where required. Resident-identifiable information should not be shared through website enquiries.
What agitation can look like
Agitation is not one behaviour. It can include pacing, repeated questioning, calling out, resisting support, exit seeking, verbal aggression, physical aggression, tearfulness, restlessness or distress that intensifies at particular times of day.
The important question is not only what the resident is doing, but what the behaviour may be communicating. In dementia care, agitation often reflects distress, confusion, pain, fear, overload or loss of control.
Start with meaning, not management
A rushed response can make agitation worse. Before trying to “stop” the behaviour, staff should consider what the person may be experiencing. The same behaviour can have different meanings for different people. Pacing may reflect pain, anxiety, boredom, a need for the toilet, a previous work routine or an attempt to find someone.
Common contributing factors
- Pain, constipation, infection, dehydration, hunger, poor sleep or medication effects
- Delirium or an acute change in physical health
- Noise, crowding, heat, lighting or overstimulation
- Fear, embarrassment or misunderstanding during personal care
- Loss of role, purpose, privacy or control
- Communication difficulties, sensory impairment or staff approaches that are too fast
Why generic care plans often fail
Care plans that say “reassure and redirect” are rarely enough. Staff need to know what reassurance sounds like for that person, what wording to avoid, what the early warning signs are, and when stepping back is safer than continuing.
A stronger plan links the visible behaviour to a working hypothesis. For example, “becomes restless after lunch and heads towards the exit because he believes he is late collecting his wife” gives staff more to work with than “wanders in afternoon”.
Mini case example
A resident was described as “agitated every evening”. Incident logs showed the behaviour was most common around shift change, when the lounge became noisy and staff were busy. The formulation suggested fatigue, noise sensitivity and reduced access to a familiar staff member. The plan focused on earlier reassurance, a quieter space, meaningful evening routine and consistent wording, rather than waiting until the resident was already distressed.
When escalation is needed
- Agitation is sudden or clearly different from baseline
- There is possible pain, delirium, infection, fall, dehydration or medication change
- There is risk of injury to the resident or others
- Safeguarding concerns are emerging
- PRN or antipsychotic medication is being considered because existing plans are not working
Sources and UK guidance basis
- NICE NG97, Dementia: assessment, management and support for people living with dementia and their carers.
- NICE QS184, Dementia: supporting people with dementia and their carers in health and social care.
- NICE CG103, Delirium: prevention, diagnosis and management in hospital and long-term care, where sudden change is relevant.
What this article cannot do
General articles can help teams think more clearly, but repeated incidents, safeguarding concerns, placement instability, complex family dynamics, prescribing questions or restrictive practice need case-specific review by the appropriate accountable professionals.
First Response Dementia Services provides focused dementia behaviour review, formulation and practical care planning support for care providers. The aim is to help teams understand the pattern, strengthen documentation and agree realistic next steps.