Reducing Anxiety and Agitation in Dementia: A Practical Guide for Families
You know something is wrong before they say a word. A restlessness in the way they are sitting. A tightness around the eyes. The beginning of something you have learned to recognise. It might pass in minutes or might build into an hour of distress that leaves you both exhausted.
Anxiety and agitation in dementia are among the most difficult experiences for families to manage at home. Not because they are unpredictable. They can be. But because watching someone you love become frightened in the place that should feel safest to them is one of the most painful parts of this condition.
Dementia UK, whose specialist Admiral Nurses work directly with families experiencing exactly this, confirms that restlessness and agitation are common in dementia and that they often stem from unmet needs, confusion, environmental factors or difficulty communicating.
Around 50 percent of people with dementia experience agitation at some point, making it one of the most frequently reported behavioural challenges families face.
This guide explains what causes anxiety and agitation in dementia, how to identify triggers, what to do in the moment and what longer-term strategies consistently reduce both the frequency and intensity of these episodes at home.
Understanding Anxiety and Agitation in Dementia: What Is Actually Happening
What Is Anxiety in Dementia?
Dementia UK describes anxiety in dementia as a feeling of nervousness, worry or unease that in some people becomes so intense it interferes with everyday life.
For a person with dementia anxiety is not simply worrying about the future. It is often a direct response to the experience of the condition itself. The confusion of not recognising familiar surroundings, the distress of not being able to find words, the fear of not knowing what is happening or what comes next.
Anxiety and dementia share overlapping symptoms, confusion, agitation and sleep disturbances, which can make it difficult to tell them apart. The Alzheimer’s Society confirms that anxiety is common in people with dementia whether they have a history of anxiety or not, and that it can be both a symptom of some forms of dementia and a response to the experience of living with cognitive decline.
What Is Agitation in Dementia?
Agitation is related to anxiety but distinct from it. Where anxiety is primarily an internal emotional experience, agitation manifests in behaviour. Dementia UK describes agitation as including pacing, trying to leave the house, shouting, repetitive actions and sundowning, the intense anxiety and confusion that typically occurs in the late afternoon and evening.
Agitation is the behaviour that families see. Anxiety is often what is driving it. Understanding this distinction matters because it changes the response. Addressing the anxious feeling, the fear, the confusion, the unmet need, is usually more effective than attempting to stop the agitated behaviour directly.
What Causes Anxiety and Agitation in Dementia?
Dementia UK identifies several common causes that families and carers can learn to identify and address.
Confusion and disorientation. The brain with dementia cannot always make sense of its environment. Familiar places can suddenly feel unfamiliar. Familiar faces may not be recognised. This disorientation is itself frightening. The fear it generates is entirely rational from inside the experience of the person with dementia.
Unmet physical needs. A person who is hungry, thirsty, in pain, too hot, too cold or needing the toilet but unable to communicate this clearly may express that unmet need through agitation. The behaviour is not the problem. The unmet need is.
Environmental overstimulation. Too much noise, too many people, too much activity. All of these increase cognitive load for a brain already working hard to process basic information. The result can be overwhelm that presents as anxiety or agitation.
Change and unpredictability. Dementia makes change significantly harder to process. A change in routine, a new face, an unfamiliar environment. Any of these can trigger anxiety disproportionate to the change itself. The familiar is safe. The unfamiliar is threatening.
Sundowning. Dementia UK confirms that sundowning, the increase in confusion, anxiety and agitation in the late afternoon and evening, affects approximately 20 percent of people with dementia.
It is linked to changes in the body clock caused by dementia and to the reduction in natural light as the day ends.
Communication difficulties. A person who cannot express what they need, what they fear or what is wrong may express it through restlessness or agitation instead. The behaviour is communication.
Warning: When Sudden Agitation Means Something Else Entirely
This is one of the most important things a family can know. And one of the least discussed.
If your loved one’s anxiety or agitation changes suddenly and significantly, over hours or days rather than weeks, do not assume it is simply dementia progressing. A sudden and pronounced increase in agitation, confusion or distress is a recognised sign of a urinary tract infection in older people.
UTIs are extremely common in elderly people and can cause acute confusion, agitation, hallucinations and a sharp deterioration in cognitive function that can look exactly like rapid dementia progression. It is not. It is a treatable infection. Prompt treatment with antibiotics usually resolves the acute confusion within days.
Other physical causes of sudden increased agitation include dehydration, constipation, pain that cannot be communicated verbally, a reaction to a new or changed medication, or delirium following illness or a hospital admission.
The NHS recommends contacting a GP promptly if a person with dementia seems suddenly more confused or distressed than usual.
https://www.nhs.uk/conditions/dementia/living-with-dementia/communication/
Do not wait. Do not assume it is simply the condition worsening. It may be something entirely and quickly treatable.
What to Do in the Moment: When Agitation Is Happening Now
This is the section most guides do not write. The strategies below are for the moment you are in the middle of. When your loved one is distressed and you need to know what to do right now.
Stay calm. This is the hardest instruction and the most important one. Agitation is contagious in both directions. A calm, slow, quiet presence communicates safety. A tense, rushed, louder response increases the sense of threat.
Lower your voice rather than raising it. Speak slowly. Use their name. Get down to their eye level if they are seated.
Do not argue or try to reason. If your loved one believes they are somewhere unfamiliar, that someone is coming, that they need to get somewhere, do not explain that this is not true. Their brain cannot hold the correction. Responding to the fear rather than the content of the fear is almost always more effective. “You seem worried. I am here with you. You are safe.” works. “But you are at home. Don’t you remember?” does not.
Try to identify the trigger. Is the room too loud? Too bright? Has someone unfamiliar just arrived? Is there a programme on the television that is disturbing? Is it late afternoon? The sundowning window? Could your loved one be hungry, thirsty, in pain or needing the toilet?
Remove the trigger where possible. Turn off the television. Move to a quieter room. Reduce the number of people in the space. Lower the lights slightly.
Offer comfort without forcing it. A calm presence nearby, a gentle voice, a familiar object, a photograph, a blanket, a piece of music from their past. Dementia UK notes that music therapy has an evidence base for reducing agitation and that meaningful activities can significantly reduce distress.
The Alzheimer’s Society also confirms that music therapy with a qualified therapist reduces agitation as a symptom of anxiety.
Do not try to physically restrain or stop movement. Pacing and repetitive movement are often self regulating responses to agitation. Allowing them to continue safely while providing a calm presence is usually more effective than attempting to stop them.
After the episode has passed check for physical needs. Was your loved one hungry, thirsty or in pain? This information helps identify the trigger and reduce the likelihood of recurrence.
Longer Term Strategies That Consistently Reduce Anxiety and Agitation in Dementia
Establish and Protect Routine
For a person with dementia routine is not simply helpful. It is a fundamental source of security. When the same things happen in the same order at the same time every day the brain does not have to work to predict what comes next. Predictability reduces anxiety at the neurological level.
Protect mealtimes, personal care routines, social activities and bedtimes. Where possible keep them at the same time each day. When changes are unavoidable introduce them gradually rather than suddenly.
Dementia UK confirms that maintaining a consistent daily routine is one of the most effective strategies for reducing anxiety in a person with dementia.
Create a Calm Environment
The Alzheimer’s Society recommends adapting the home to feel calmer, safer and less stressful as a key strategy for reducing anxiety.
Reduce background noise. Turn off televisions and radios that are on but not being watched or listened to. Background noise is a significant source of cognitive load for a person with dementia.
Maintain consistent, comfortable lighting. Avoid harsh overhead lighting that creates shadows. Natural light during the day supports the body clock. Warm, lower lighting in the evening helps signal the transition toward rest.
Reduce clutter. A visually complex environment is harder for the brain with dementia to process. Clear, uncluttered spaces with familiar objects in consistent positions reduce confusion and disorientation.
Identify and Manage Triggers
Agitation rarely happens without a trigger. Though the trigger may not always be obvious. Over time families often learn to recognise patterns.
Keep a simple diary noting when episodes of agitation occur, how long they last, what was happening immediately before and what seemed to help. Patterns often emerge. Particular times of day, particular activities, particular visitors or particular environmental changes.
Dementia UK identifies common triggers as including too much noise, too many people, changes in routine, unmet physical needs and sundowning.
Meaningful Activity and Social Connection
Boredom and under stimulation are significant contributors to restlessness and agitation in dementia. A person who has nothing meaningful to do, no one to talk to and nowhere to go has more cognitive space for anxiety to fill.
Meaningful activity does not mean activity for its own sake. It means things that connect to who your loved one is. Their interests, their history, their sense of purpose. Gardening, cooking simple meals together, looking through photographs, listening to familiar music, gentle exercise or a walk. These things provide engagement and reduce the space available for anxiety.
Age UK recommends encouraging regular meaningful activity as a key strategy for supporting emotional wellbeing in people with dementia at home.
Manage Sundowning Specifically
For families whose loved one experiences sundowning, the late afternoon and evening increase in agitation, specific strategies help.
Draw curtains before dusk to prevent the change in light levels that triggers sundowning. Gradually dim indoor lighting from mid afternoon. Maintain a calm, consistent evening routine. Reduce stimulation in the two hours before bed. Fewer people, less noise, familiar calming activities.
If your loved one expresses a strong desire to go somewhere in the evening, to go home, to pick someone up, to get somewhere, do not immediately contradict them. Ask about it. Walk with them briefly if safe to do so. Offer a warm drink and gentle redirection. Dementia UK confirms that sundowning can often be managed using these non pharmacological strategies without medication.
Non Pharmacological Approaches First
All clinical guidance, from the NHS, the Alzheimer’s Society and Dementia UK, is consistent on this point: non pharmacological approaches should be the first line of response to anxiety and agitation in dementia.
Medication for agitation in dementia is generally only recommended when other strategies have not worked and the distress is severe. This is because antipsychotic medications carry significant risks in elderly people with dementia, including increased risk of stroke and falls, and should only be used with careful medical supervision.
If your loved one’s anxiety or agitation is severe and not responding to the strategies above speak to their GP. A referral to a specialist old age psychiatrist or memory clinic may be appropriate. Do not attempt to manage severe distress alone without professional support.
The Impact on Family Carers: What Nobody Talks About Enough
Managing anxiety and agitation in a loved one with dementia is one of the most emotionally demanding aspects of caring at home. The unpredictability is exhausting. The not knowing what triggered it is frustrating. The watching someone you love frightened is, in an honest word, heartbreaking.
Many family carers describe a version of hypervigilance. Always watching for the early signs, always monitoring the environment for triggers, always half present even in moments of calm because the next episode could begin without warning.
This level of sustained alertness takes a significant toll. Age UK recognises that family carers supporting people with dementia are at increased risk of depression, anxiety and physical health problems themselves, and that accessing support early significantly reduces this risk.
If you are managing anxiety and agitation at home alone do not wait until you are at the point of crisis to seek support. Contact your GP. Contact Dementia UK’s Admiral Nurse helpline on 0800 888 6678. Speak to your local authority about a carer’s assessment. You are entitled to support. Not just your loved one.
How Professional Dementia Care at Home Reduces Anxiety and Agitation
The consistent presence of the same familiar carer is one of the most clinically significant factors in reducing anxiety in a person with dementia. And one that is often underestimated.
Every new face is a potential trigger. Every unfamiliar voice, every different routine, every person who has to introduce themselves and explain why they are there increases the cognitive and emotional load on a person with dementia. A rota of different carers is not just inconvenient. It is a repeated source of disorientation and potential distress.
A professional carer who visits consistently, the same person, at the same times, following the same routine, becomes a cognitive anchor. Someone the person with dementia recognises. Someone who knows what calms them, what triggers them, what their face looks like before an episode begins and what usually helps when one does. This knowledge cannot be replicated by a different person arriving for the first time.
To learn more about professional dementia care at home from a consistent familiar carer visit our dementia care at home page.
For families whose loved one needs support throughout the day and night our live in dementia care service provides a dedicated carer in the home around the clock.
For more guidance on supporting a loved one with dementia at home visit our dementia care advice hub.
Professional Review and Clinical Guidance
This guide has been reviewed by Daniel Johnson, Registered Care Manager, dementia specialist and psychologist at NeeryVille Care, a Care Quality Commission (CQC) regulated home care provider supporting individuals across England with live in care, dementia care and elderly care at home.
Daniel has more than 12 years of experience working in the health and social care sector, supporting individuals living with dementia at every stage of the condition. His background in psychology gives him a particular understanding of anxiety in dementia, how it develops, what drives it and what actually works to reduce it in the context of daily life at home.
“Families often feel a profound guilt about not being able to prevent episodes of agitation. They ask themselves what they did wrong, what they missed, what they should have spotted earlier. The honest answer is that anxiety and agitation in dementia are not a failure of care. They are a symptom of a condition. What families can do, and what makes an enormous difference, is understand the triggers, reduce the environmental causes and respond in a way that communicates safety rather than urgency. That is learnable. And it changes everything.”
Daniel Johnson, Registered Care Manager, NeeryVille Care
The information in this guide aligns with recognised guidance from the NHS, the Alzheimer’s Society and Dementia UK.
Frequently Asked Questions
What causes anxiety and agitation in dementia?
Anxiety and agitation in dementia are usually caused by a combination of factors including confusion and disorientation, unmet physical needs such as hunger, thirst or pain that cannot be communicated verbally, environmental overstimulation such as too much noise or too many people, changes in routine or unfamiliar faces, and sundowning, the increase in confusion and agitation in the late afternoon and evening. A sudden increase in agitation can also indicate a urinary tract infection or other treatable physical condition.
How do you calm someone with dementia who is agitated?
Stay calm and lower your voice. Speak slowly and use their name. Do not argue or try to reason. Respond to the fear or distress rather than the content of what they are saying. Try to identify and remove the trigger. Offer comfort through a calm presence, familiar music, a warm drink or a familiar object. Allow safe repetitive movement such as pacing rather than trying to stop it. After the episode check for unmet physical needs.
What is sundowning and how do you manage it?
Sundowning is a recognised pattern in dementia where confusion, anxiety and agitation increase in the late afternoon and evening. It affects approximately 20 percent of people with dementia. It can be managed by drawing curtains before dusk to prevent light level changes, maintaining a consistent calm evening routine, reducing noise and stimulation from mid afternoon and offering gentle redirection rather than confrontation when the person expresses a strong desire to go somewhere.
Should someone with dementia be given medication for anxiety?
All clinical guidance recommends non pharmacological approaches, including routine, environment, communication and meaningful activity, as the first line of response to anxiety and agitation in dementia. Medication is generally only considered when other strategies have not worked and distress is severe, because antipsychotic medications carr significant risks in elderly people with dementia. Speak to a GP if anxiety or agitation is not responding to other strategies.
What is the difference between anxiety and agitation in dementia?
Anxiety is primarily an internal emotional experience, the feeling of fear, worry or unease. Agitation is how that anxiety manifests in behaviour, pacing, restlessness, shouting, repetitive actions or attempts to leave. Addressing the underlying anxiety, the unmet need, the confusion and the fear is usually more effective than attempting to stop the agitated behaviour directly.
When should I contact a GP about anxiety or agitation in dementia?
Contact a GP if anxiety or agitation increases suddenly over hours or days rather than weeks. This can indicate a treatable physical cause such as a urinary tract infection, dehydration or pain. Also contact a GP if anxiety or agitation is severe, is not responding to non pharmacological strategies or is putting your loved one or others at risk. Do not manage severe distress alone without professional support.