Alzheimer Disease Insights: It's Not All About Cognition, Counsels George Grossberg, MD

Patient Care® spoke recently with George Grossberg, MD, a physician scientist and expert in geriatric psychiatry about agitation in Alzheimer's disease (AD), a focus among his other topics of inquiry. Grossberg emphasized in this segment of the conversation the neuropsychiatric concomitants of AD, appreciation of which he deems an important expansion of perspective on the disease and on the adults and families affected.

The transcript below has been lightly edited for length and clarity.

George Grossberg, MD: I wouldn’t call it a trend exactly, but I have observed something quite new and positive in Alzheimer’s care. For many years, our focus in Alzheimer’s disease was heavily centered on cognition—how we could slow cognitive decline, improve symptoms, or enhance diagnostic accuracy, distinguishing Alzheimer’s from other dementias. However, we paid relatively little attention to the behavioral or neuropsychiatric aspects, like agitation, which are also key features of the disease. This is changing now. When we talk about neuropsychiatric symptoms, we’re looking at issues such as depression, anxiety, psychosis, hallucinations, delusions, apathy, and, perhaps most distressing, agitation. It feels like we’re entering a new era in which these symptoms are being addressed more directly and thoroughly.

As for agitation, there are certainly characteristic symptoms in Alzheimer's patients that can distinguish it from co-occurring psychiatric conditions or other neurodegenerative diseases. One of the key things we want primary care providers to remember is to consider a broader context. For instance, if an Alzheimer’s patient, who has generally been stable and manageable, suddenly begins to exhibit new agitated behaviors, it’s important not to immediately attribute this to the progression of their Alzheimer's. Instead, we should think about potential triggers or underlying causes for their agitation.

Common triggers include factors that cause delirium or acute confusion, such as infections like a urinary tract infection, or new medications that may cloud the patient’s thinking. Pain is another big one—sometimes the patient can’t verbalize their discomfort, and it manifests as agitation. Depression can also play a role. In older adults, we often see two types of depression: one is more apathetic, where the person is listless and quiet, and the other is agitated depression, marked by heightened psychomotor activity, which could be mistaken for agitation due to dementia.

Psychosis is another major symptom associated with various dementias, including Alzheimer's, that can trigger agitation. I recently saw a patient referred for agitation, and the nurses' aides reported that she sometimes talks to people who aren’t there, staring at a corner or outside the room. She might be experiencing threatening hallucinations, which understandably could lead to agitated behavior.

So, before concluding that agitation is simply a symptom of Alzheimer’s, we need to rule out other potentially treatable causes. Addressing these underlying factors can make a big difference in managing agitation effectively.

George T Grossberg, MD, is the Samuel W. Fordyce professor and director of geriatric psychiatry in the department of psychiatry at Saint Louis University School of Medicine. He is a past president of the American Association for Geriatric Psychiatry and of the International Psychogeriatric Association. Grossberg's research focus includes behavioral symptoms in Alzheimer disease and novel therapies for neurocognitive disorders.