How I Treat: Addressing Sudden Escalation in Agitation Due to Alzheimer Disease Case Presentation

An 82-year-old female presents to your psychiatry practice for the first visit with notable behavioral changes, as reported by her husband. The patient remains generally pleasant during the clinic visit and continues to engage with a book throughout the examination. 

Her husband expresses concern regarding a significant escalation in the patient's behavior over the past few weeks. Specifically, he recounts a recent incident during a surprise birthday celebration orchestrated by their daughter, which culminated in a “raging fit.” Following this event, the patient has experienced multiple episodes characterized by aggressive outbursts, including cursing at family members. The husband highlights an alarming incident that occurred 1 week prior to their visit, where the patient physically struck him as he assisted her in tying her shoes for an outing. 

Historically, the husband has successfully managed the patient's agitation through calming activities, such as visits to the library. However, recent visits have taken a troubling turn, with the patient now yelling obscene remarks at other library patrons.

The husband is seeking guidance on how to address these troubling changes in his wife's behavior and is concerned about her increasing aggression and loss of control in public settings. Further evaluation and intervention strategies are necessary to support both the patient and her family.

Patient history: 

• Married for 47 years with 1 daughter and 2 grandchildren
• Retired teacher and volunteered at the public library
• No family history of neurological conditions
• Hypertension
• Dementia (diagnosed 2 years ago)

Her current medications (all being managed by her PCP) include:

• Amlodipine, 10 mg once daily
• Escitalopram (Lexapro), 5 mg once daily
• Donepezil (Aricept), 5 mg at bedtime
• Divalproex sodium (Depakote), 125 mg twice daily 

To treat this patient’s sudden escalation in agitation, the most appropriate primary treatment approach would likely be option C: to discuss adjusting the patient’s psychotropic medications. 

In this case, Williams suggests initiating brexpiprazole, which is Food and Drug Administration (FDA)-approved for the treatment of agitation associated with dementia, to quickly see adjustments in the patient’s behavior. Because brexpiprazole can be prescribed and managed by mental health providers, this option mitigates the need to send the patient to other clinicians for further evaluations or testing. Targeting the patient’s agitation also ensures that she is able to safely continue living at home, spending time with her family, and enjoying trips to the library.  

Kevin N. Williams MS, MPAS, PA-C, is the CEO and lead clinician at OnPoint Behavioral Health. He is a physician associate that specializes in psychiatry and has a mission to provide care that is experienced, holistic, and compassionate. He holds two master degrees in Interdisciplinary Medical Sciences and Physician Assistant Studies from the University of South Florida and South University, respectively. He has gained experience treating children, adolescents, and adults for the past 10 years in the areas of inpatient, outpatient, and long-term care. Williams has 8 years of experience teaching as an adjunct professor at several institutions around the country. He also has over 10 years in executive leadership experience and maintains a passion of educating others to lead with effective influence.

© 2025 HMP Global. All Rights Reserved. 

Any views and opinions expressed above are those of the author(s) and do not necessarily reflect the views, policy, or position of the Psych Congress Network or HMP Global, their employees, and affiliates.