TABLE 2.

Suggested Approach to the Evaluation of Patients with Dementia Presenting with Psychosis and or Agitation^*/Agression

1)	Establish the dangerousness of the situation.
	•	If the physical safety of the patient or others is at significant risk, and the patient does not respond quickly to behavioral strategies (e.g. verbal redirection/reassurance, stimulus reduction, change of environment), acute treatment with pharmacotherapy could be considered. For instance, offer the patient oral antipsychotic medication (possibly in dissolvable tablets for ease of administration) and then if necessary consider intramuscular medications (e.g. olanzapine, aripiprazole, haloperidol, lorazepam).
	•	For less acute situations, conduct a more thorough investigation of the symptom etiology and an informed consent process prior to any treatment.
2)	Establish a clear diagnosis/etiology (to the extent possible) for the symptoms.
	•	Rule out delirium (e.g. urinary tract infection, subdural hematoma, pneumonia) through appropriate physical examination and diagnostic studies.
	•	Rule out iatrogenic causes (e.g. explore recent changes in medications).
	•	Rule out physical discomfort (e.g. arthritis pain, unrecognized fracture, constipation).
	•	Explore for common antecedents to symptom flares that are potentially modifiable (e.g. seeing a certain person, increased noise level, social isolation).
	•	Explore other common causes of behavioral disturbances in dementia (e.g. depression, anxiety, insomnia).
3)	Establish the severity and frequency of the symptoms, including:
	•	Impact on patient quality of life
	•	Impact on caregiver quality of life
	•	Instances in which the physical safety of the patient or others have been jeopardized
	•	Clear delineation/description of prototypical examples of the symptoms
4)	Explore past treatments/caregiver strategies used to address the symptoms and their level of success and/or problematic outcomes of such treatments
5)	Discuss what is known (and probably more importantly what is not known) about possible risks and benefits of treatments (pharmacological and non-pharmacological) for psychosis and agitation/aggression in dementia, including atypical antipsychotics

^*Agitation for the purposes of this paper is defined as “inappropriate verbal, vocal, or motor activity that is not judged by an outside observer to be an obvious outcome of the needs or confusion of the individual (19).”