We had a resident whose behavior changed dramatically.

She had experienced some dementia-related behaviors before. That wasn’t unusual. But this was different.

She suddenly became much more erratic. She was raising her voice. She was extremely difficult to calm. The change was significant enough that the most important observation wasn’t simply, “She is agitated.” It was: “This isn’t normal for her.”

That distinction matters when you’re trying to understand how to help when dementia leads to agitation.

Our clinical team considered whether something physical or medical might be contributing to such a sudden change. A urine analysis was obtained as part of her clinical evaluation. A urinary tract infection was identified, her medical provider appropriately evaluated and treated her, and the dramatic behavioral escalation resolved.

Over the years, this became a pattern with this particular resident. When her behavior suddenly changed significantly, the team knew that a medical or physical issue was something worth considering rather than simply assuming her dementia was getting worse.

There is an important caution here. I am not saying that agitation means someone has a UTI. It doesn’t. Older adults can have bacteria in their urine without having a symptomatic urinary tract infection. Clinical guidelines specifically caution against assuming that bacteriuria plus a mental-status change automatically establishes a UTI or warrants antibiotics. Testing and treatment require appropriate clinical judgment. The Infectious Diseases Society of America explains this distinction in its guideline on asymptomatic bacteriuria.

The lesson from this resident was much broader: when behavior suddenly changes, pay attention to the change.

When someone with dementia becomes agitated, the first question shouldn’t always be, “How do we stop this?” Sometimes the more important question is: “Why is this happening?”

What Is Agitation in Dementia?

Agitation can look different from person to person.

The National Institute on Aging describes agitation as restlessness and worry accompanied by difficulty settling down. It can include pacing, sleep problems, verbal outbursts or aggressive behavior. The NIA offers additional guidance on agitation, aggression and sundowning.

In everyday dementia care, families may describe someone who is pacing or repeatedly getting up, yelling or raising their voice, becoming unusually angry, resisting bathing or dressing, repeatedly trying to leave, unable to settle, increasingly restless, or reacting strongly to a particular person or situation.

The label itself doesn’t tell us why the behavior is happening. That’s why I think of agitation as a behavior or symptom—not an explanation.

How to Help When Dementia Leads to Agitation: Start With Why

If you’re trying to understand how to help when dementia leads to agitation, I would think through the situation approximately in this order.

First: Is something medically or physically wrong? Especially ask this when the behavior is sudden, severe or significantly different from the person’s normal baseline.

Second: Is there a pattern? Does it happen at approximately the same time every day? Around the same task? With the same caregiver? In the same environment?

Third: Is something about the environment or caregiving approach contributing? Is the room noisy? Is the person being rushed? Are there too many instructions? Are several people talking? Are we asking them to do something they don’t understand?

Fourth: What might the person be trying to communicate? Pain? Fear? Hunger? Thirst? Fatigue? Needing the bathroom? Boredom? Confusion? Wanting to leave? Simply not wanting to do what we’re asking right now?

And finally: Can we change our approach instead of trying harder to change the person?

Sometimes the answer is not more persuasion. It may be trying later, trying another caregiver, using fewer words, changing the environment, changing the timing, redirecting toward something meaningful, or stopping and reassessing.

This isn’t a medical algorithm. It’s a way of becoming curious before becoming more forceful.

Why Does Dementia Cause Agitation?

There isn’t one cause.

Dementia itself changes how someone understands and processes the world around them. But agitation may also be influenced by pain, stress, inadequate sleep, constipation, changes in routine, excessive noise or stimulation, loneliness, being pushed to complete a difficult task, and certain medications or medication interactions. The National Institute on Aging discusses these and other possible contributors.

Think about how many things we ordinarily communicate with words: “My hip hurts.” “I need to use the bathroom.” “I don’t know who you are.” “This room is too loud.” “I’m exhausted.” “I don’t understand why you’re taking my clothes off.” “I don’t want a shower right now.” “I want to go home.”

A person living with dementia may no longer be able to express those thoughts clearly. Instead, we see the behavior.

That’s what I mean when I say: Behavior is communication.

But I want to add an important qualifier. Not every episode of agitation has an emotional explanation that a caregiver can discover. Sometimes the cause remains unclear. Sometimes the behavior is severe. Sometimes medical treatment is appropriate. Sometimes there is a genuine safety concern. And sometimes the behavior represents an acute physical or medical change.

The phrase “behavior is communication” should make us more curious. It should not make us less serious about the behavior.

A Sudden Change May Mean Something Else Is Going On

This is one of the most important distinctions families can learn.

Dementia changes over time. Delirium is different. It typically develops suddenly—over hours or days—and can involve confusion, disorientation, changes in attention, sleepiness or agitation. Potential causes include infection, dehydration or electrolyte problems, medication effects, serious illness, severe pain and sleep deprivation. People with dementia and older adults are at increased risk. MedlinePlus provides an overview of delirium and its causes.

That doesn’t mean a family should diagnose delirium—or decide on the cause themselves. It means a sudden departure from someone’s baseline deserves attention.

The Alzheimer’s Association recommends medical evaluation for behavioral symptoms, particularly when they appear suddenly.

Our resident’s UTI is a useful example precisely because it teaches us to notice change without turning one resident’s experience into a universal rule.

A UTI can occur alongside an acute behavioral or mental-status change in an older adult. But older adults also commonly have bacteria in their urine without symptomatic infection. IDSA guidance cautions clinicians to look for other causes rather than automatically treating bacteriuria in an older cognitively impaired person whose only new finding is delirium or confusion and who lacks urinary symptoms or systemic signs.

So the takeaway isn’t, “Agitation? Check for a UTI.” It’s: “This person is suddenly very different. What changed?”

Before Trying to Stop the Behavior, Look for the Pattern

Sometimes agitation isn’t sudden at all. Sometimes it’s remarkably predictable.

We cared for a gentleman who had a very clear pattern. At approximately 3 p.m., he would often begin becoming agitated.

His family told us that at his previous community, the response had increasingly focused on medication. They felt his medication had been increased to the point where he was heavily sedated.

At The Sanctuary, we didn’t want him spending his day in a heavily sedated state. His medication regimen was appropriately evaluated by his medical provider.

But the team also started paying attention to something else: When was this happening?

It was predictable. That mattered.

Under the direction of his medical provider, his prescribed regimen could be managed with awareness of that established pattern rather than simply reacting after he was already significantly distressed.

But medication was only part of the response. We also learned what helped him.

He enjoyed watching a particular sports show. Afterward, he liked sitting outside and watching birds. So we added a bird feeder. That became part of his routine.

What helped wasn’t one magical dementia intervention. It was a combination of appropriate clinical management, recognizing the pattern, intervening before he became highly distressed, familiar routine, something he genuinely enjoyed, time outside, and an environment that helped him settle.

Know the person. Know the pattern. And when medication is involved, work with an experienced medical provider.

What Is Sundowning?

Some people living with dementia experience increased confusion, restlessness, anxiety, agitation, pacing or disorientation later in the day or into the night. This collection of symptoms is commonly called sundowning. The Alzheimer’s Association explains sundowning and ways caregivers can respond.

It doesn’t necessarily begin precisely at sunset. And not every person who becomes agitated at 3 p.m. is experiencing sundowning.

Possible contributors include fatigue, disrupted sleep-wake patterns, unfamiliar or confusing surroundings and other changes associated with dementia.

The useful lesson for families is pattern recognition. Keep track of when the behavior happens. What happened beforehand? Was the day unusually busy? Did the person sleep poorly? Is the environment becoming darker? Are they hungry? Is the room getting busier? Does this happen every afternoon or was today unusual?

A pattern doesn’t always give you the answer. But it gives you information.

Medication Can Be One Tool — But It Shouldn’t Be the Only Tool

I don’t think medication should be portrayed as either inherently good or inherently bad in dementia care.

Sometimes medication is appropriate and important. Medication decisions involve meaningful risks and benefits and belong with qualified clinicians who understand the individual. The Alzheimer’s Association discusses medication and non-drug approaches to agitation.

What I don’t want is for medication to become a substitute for curiosity.

If someone is in pain, frightened by an unfamiliar caregiver, overwhelmed by noise, desperately needs the bathroom or becomes distressed during a particular task, those observations matter.

Non-drug approaches—including modifying the environment, simplifying routines and using individualized psychosocial strategies—remain important parts of managing agitation.

Our gentleman who became agitated around 3 p.m. is a good example. Medication mattered. So did the sports show. So did the birds. So did going outside. So did knowing when the behavior usually started.

It wasn’t medication or individualized dementia care. It was thoughtful clinical management plus individualized dementia care.

Families should never change a prescription, dose or medication schedule on their own based on something they read online. Those decisions belong with the person’s prescribing clinician.

Sometimes “No” Means “Not Right Now”

We had another gentleman who absolutely resisted showering.

When caregivers asked him to shower, he could become extremely agitated.

There wasn’t one clever intervention that fixed it. It took weeks.

Our caregivers tried different approaches and gradually learned several things about him.

One particular caregiver was much more successful at helping him agree to a shower. He was also more receptive during the early evening. And even then, she might have to approach him three or four separate times before he finally agreed.

I think that last detail is particularly important.

Sometimes the first answer is: “No.” And the solution isn’t necessarily: “Try harder.” Sometimes it’s: “Try again later.”

Eventually, we knew who he trusted. We knew when he was more receptive. And we knew more about how to approach him.

That’s individualized dementia care.

Why Relationship and Timing Matter in Dementia Care

Imagine someone you don’t recognize telling you to take off your clothes.

You say no. They keep insisting. You still don’t understand why this person is in your room or why they want you to undress.

From the caregiver’s perspective, the task is a shower. From your perspective, something frightening may be happening.

This is why labels like “noncompliant” can be so unhelpful. They describe the outcome without telling us anything about the experience.

The National Institute on Aging specifically identifies being pushed to do something—such as bathing—that dementia has made difficult or confusing as one possible contributor to agitation. It recommends patience, calm communication, reduced stimulation, routine and redirection toward familiar activities.

Sometimes a familiar caregiver has more success because trust has developed. Sometimes morning is terrible and evening works. Sometimes fewer words work better. Sometimes asking permission changes the interaction. Sometimes nothing works on the first attempt.

And sometimes that’s okay.

Good Dementia Care Requires Enough Caregiver Bandwidth to Try Again Later

This is one of the less obvious things I’ve learned about dementia care.

Patience requires time.

If someone refuses a shower at 10 a.m., a caregiver may need to stop. Someone may try again at noon. And again later. Maybe a different caregiver needs to try. Maybe the resident needs to eat first. Maybe they need a walk. Maybe today simply isn’t going according to schedule.

That flexibility requires more than good intentions. It requires time, staffing, patience, consistency and relationship.

Good dementia care sometimes requires enough caregiver bandwidth to try again later.

That’s one reason staffing matters beyond simply completing physical tasks.

At The Sanctuary, our six-resident residential homes and consistent caregivers make it easier to notice patterns and know individual residents over time. Our RN oversight and medical partnerships also matter when a change may require clinical evaluation. You can learn more about our broader approach to memory care in Charlotte and our dementia care team.

But I don’t want to overstate this. No staffing model eliminates agitation. No caregiver knows the answer every time. And not every behavior can safely be supported in every residential setting.

The point is simply that knowing a person—and having enough time to respond flexibly—changes what is possible.

What Might the Person Be Trying to Tell You?

When agitation develops, consider questions like these: Is this suddenly different from their normal baseline? Could they be in pain? Are they hungry or thirsty? Do they need the bathroom? Could constipation or another physical discomfort be contributing? Are they tired? Are they too hot or too cold? Is the environment noisy or crowded? Are too many people talking? Are they being rushed? Are we giving too many instructions at once? Do they understand what we’re asking? Do they recognize the caregiver? Could they be frightened? Have they been sitting for a long time? Would movement help? Are they bored or looking for something to do? Does this happen at the same time every day? Does it happen around the same task? Has the routine changed? Has a medication recently changed? Is this an established pattern—or something completely new?

You may not find the answer. That’s important to say.

Sometimes caregivers do everything thoughtfully and the agitation persists. The goal isn’t to convince families that every behavior is a puzzle they should be able to solve. The goal is to gather better information.

What Can You Do in the Moment to Calm Dementia Agitation?

When someone is already becoming agitated, your first goal usually isn’t to solve every underlying problem. It’s to keep the interaction from becoming more distressing while you assess what may be happening.

Start with yourself. Slow down. Lower your voice. Give the person more physical and conversational space. If several people are talking, let one familiar person take the lead.

Use clear and calm communication. Instead of giving several instructions at once, simplify the task into one small step. Avoid lengthy explanations or trying to prove that the person is mistaken.

Look at the environment too. Turn down the television. Reduce unnecessary background noise. Move away from a crowded room if possible. If the person seems overwhelmed, a familiar quiet space may be more helpful than continuing the conversation where you are.

Then consider gentle redirection. That might mean offering a drink, going for a walk, sitting outside, listening to familiar soft music, looking through photographs, folding towels or moving toward another familiar activity. A favorite personal item or familiar routine can sometimes provide a sense of security.

Offer guided choices rather than open-ended questions when choices are helpful. “Would you like to sit here or by the window?” can be easier to process than “What do you want to do?”

Physical reassurance is more individual. A hand on someone’s arm or holding their hand may be comforting if that person normally welcomes touch. For someone who is frightened, angry or doesn’t recognize you, unexpected physical contact can increase distress. Don’t assume touch is calming simply because it is intended to be reassuring.

And if the agitation is centered around a non-urgent task—like the shower in our earlier story—consider whether the best de-escalation technique is simply to stop.

You don’t have to win the interaction.

Sometimes walking away and trying again later is the intervention.

Change the Environment Before Assuming You Need to Change the Person

The physical environment can contribute to agitation in ways that are easy to miss.

A television playing in the background, people talking across the room, clutter, confusing furniture arrangements, changing shadows, poor lighting or too many demands happening at once can make an already confusing world more difficult to interpret.

Look around from the person’s perspective. Could you reduce background noise? Could you declutter the immediate area or simplify what is visually competing for attention? Would better natural light or softer lighting make the space easier to understand? Is there a familiar chair, photograph, blanket or other personal item that provides reassurance? Could the person move to a quieter space? Would a familiar activity, soft music or established soothing ritual help them settle?

This doesn’t mean redecorating the house every time someone becomes upset. It means recognizing that environmental triggers are part of the behavior equation.

Sometimes changing the surroundings is more effective than repeating the same request more forcefully.

Don’t Just Track the Agitation. Track What Happens Before It.

When agitation happens repeatedly, memory alone isn’t always the best way to identify the pattern.

For several days, consider keeping a simple record: When did it happen? What happened immediately beforehand? Who was there? What was the person being asked to do? Had they eaten? Had they slept? Was the environment noisy or busy? What were the earliest verbal or nonverbal cues of distress? What did you try? What seemed to help?

You aren’t trying to create a clinical diagnosis. You’re looking for patterns.

Maybe agitation repeatedly begins before dinner. Maybe showering is consistently difficult in the morning but easier later. Maybe a particular television program creates background noise at exactly the time the person becomes restless.

Maybe you begin seeing early warning signs—pacing, repetitive questions, a change in facial expression, increasingly rapid speech or an inability to settle—before the behavior escalates.

Recognizing those cues can sometimes give you an opportunity to adapt the routine or environment earlier.

Our gentleman who became agitated around 3 p.m. is a good example. The team didn’t merely know that he became agitated. They knew when it tended to happen.

That allowed his medical provider and caregivers to think proactively rather than waiting for the most difficult part of the episode.

His familiar sports program, time outside and bird feeder also created predictability and routine around a part of the day that had historically been difficult.

Consistent routines can be reassuring for many people living with dementia. But consistency doesn’t mean rigidity.

If the established routine repeatedly creates distress, adapt it.

The goal isn’t, “We always shower at 10 a.m.” The goal is, “What routine helps this particular person feel safest and most comfortable?”

When Should Sudden Agitation Be Medically Evaluated?

A sudden or dramatic behavioral change deserves particular attention.

Contact an appropriate healthcare professional when agitation is new, markedly worse than usual or accompanied by other concerning changes such as signs of illness, new pain, substantial changes in alertness, inability to maintain normal food or fluid intake, a recent fall or injury, or other acute physical or neurological changes.

Sudden confusion can represent delirium, which may have an underlying medical cause and warrants evaluation. MedlinePlus provides more information about delirium.

If someone’s behavior creates an immediate danger to themselves or others, treat that as a safety issue and seek appropriate emergency assistance.

This isn’t about becoming alarmed every time someone with dementia has a difficult afternoon. It’s about knowing the baseline well enough to recognize when something is meaningfully different.

That is also why a thoughtful memory care assessment needs information from the family about the person’s ordinary routines, behaviors and responses—not simply a snapshot from one conversation.

How We Think About Agitation at The Sanctuary

The broader philosophy is simple: Behavior is communication.

But the practical application is more nuanced.

Recognizing a change from baseline requires knowing the baseline. Recognizing that someone consistently becomes agitated around 3 p.m. requires observing the pattern. Knowing that one particular caregiver can help someone shower requires caregiver consistency. Trying four separate times requires bandwidth. Knowing that someone likes a particular sports program and watching birds requires knowing the person.

Those aren’t just amenities. They are part of dementia care.

Our existing article about challenging behaviors in dementia explores that broader philosophy. This article is intentionally narrower because agitation deserves its own question: What is happening right now, and what might be driving it?

Sometimes the answer involves medical evaluation. Sometimes it involves appropriate medication management. Sometimes it involves changing the environment. Sometimes it involves changing caregivers. Sometimes it involves stopping, walking away and trying again. Often it involves several of those things together.

And sometimes, despite everyone’s best efforts, the behavior remains difficult.

Good dementia care isn’t the promise that nobody will ever become agitated. It’s the willingness to keep asking: “What might this person need from us right now?”

Key Takeaways

• Agitation is a behavior or symptom. It isn’t an explanation.
• A sudden or dramatic departure from someone’s usual behavior deserves attention because a medical or physical issue may be contributing.
• Agitation does not automatically mean UTI, and a positive urine test does not by itself establish that a UTI caused a behavioral change.
• Look for patterns: time of day, particular tasks, caregivers, environments and events immediately preceding the behavior.
• “Behavior is communication” means becoming curious about what may be driving the behavior—not assuming every episode has an easy explanation.
• Pain, fear, fatigue, hunger, toileting needs, constipation, overstimulation, medication effects, illness and changes in routine can all contribute.
• Sundowning can involve increased confusion, restlessness or agitation later in the day, but not every afternoon episode is sundowning.
• Medication can be appropriate, but medication decisions belong with qualified clinicians and should not replace attention to environmental and behavioral contributors.
• Sometimes “no” means “not right now.”
• Good dementia care sometimes requires enough caregiver bandwidth to try again later.
• The goal isn’t perfect compliance. It’s safety, dignity, comfort and understanding.

Frequently Asked Questions

What causes agitation in dementia?

There is no single cause. Dementia-related brain changes can contribute, but agitation may also be associated with pain, fatigue, constipation, hunger, thirst, overstimulation, fear, confusing tasks, environmental changes, medication effects, illness or other physical problems. Sudden behavioral changes deserve particular attention.

How do you calm someone with dementia who is agitated?

Start by checking safety and looking for possible physical discomfort or a sudden medical change. Speak calmly, reduce stimulation, avoid arguing, simplify what you’re asking, offer reassurance and consider redirecting toward a familiar or enjoyable activity. If a task is creating distress and can safely wait, trying again later may work better than pushing harder.

Can pain cause agitation in dementia?

Yes. Pain is among the physical problems that can contribute to agitation or changes in behavior. This is particularly important when a person can no longer clearly describe where or how they hurt.

Can a UTI cause sudden behavior changes in someone with dementia?

Infection, including urinary tract infection, can occur alongside delirium and acute behavioral or mental-status changes. But agitation or confusion alone does not prove that someone has a UTI, and bacteria in an older adult’s urine may be present without symptomatic infection. Appropriate clinical evaluation is important.

What is sundowning?

Sundowning refers to increased confusion or dementia-related behaviors that occur later in the day or into the night. Symptoms can include agitation, anxiety, pacing, disorientation and sleep difficulties.

What time does sundowning happen?

There is no exact clock time. Symptoms often become more noticeable in the late afternoon, evening or as daylight fades, but patterns vary by person.

What can trigger sundowning?

Potential contributors include fatigue, disrupted sleep-wake rhythms, unfamiliar or confusing surroundings and other dementia-related changes. Observing the person’s daily pattern can help caregivers identify possible triggers.

Should medication be used for dementia agitation?

Sometimes. Medication can be appropriate depending on the cause, severity, risks and individual clinical circumstances. Non-drug approaches remain important, and medication decisions should be made by qualified clinicians familiar with the individual.

Why do people with dementia refuse showers?

A person may not understand what is happening, may not recognize the caregiver, may feel cold or frightened, may dislike the timing or may simply not want a shower at that moment. Dementia can make a familiar task confusing or threatening. Pushing harder can sometimes increase agitation.

What should you do when someone with dementia refuses care?

When it is safe to do so, back off and consider what might be causing the resistance. Try another time, simplify the request, reduce stimulation or consider whether another familiar caregiver may have better rapport. A refusal may sometimes mean “not right now” rather than “never.”

What does “behavior is communication” mean in dementia care?

It means behavior may convey discomfort, fear, confusion, a physical need, frustration or another experience that the person can no longer clearly express in words. It doesn’t mean every behavior has an obvious explanation or that medical causes should be overlooked.

What stage of dementia causes agitation?

Agitation is not limited to one precise dementia stage. Behavioral symptoms can occur at different points and vary substantially among individuals. A new or sudden change should not simply be attributed to disease stage without considering other causes.

What is terminal agitation in dementia?

“Terminal agitation” or terminal restlessness generally refers to agitation that can occur near the end of life and should not be assumed to be ordinary dementia-related agitation. New agitation in someone believed to be nearing end of life should be discussed with the person’s hospice or medical team so potentially treatable sources of distress and appropriate comfort measures can be evaluated.

You May Also Find These Helpful

Challenging Behaviors in Dementia: How We Approach Them

Why People With Dementia Wander (and Why It Isn’t the Same as Exit Seeking)

Memory Care Assessment: What Should It Really Evaluate?

If you’re trying to understand a change in your loved one’s behavior and wondering whether a different dementia-care environment may help, contact The Sanctuary. Tell us what is actually happening—including the difficult parts. Those details help us have a much more useful conversation about whether our model may be an appropriate fit.