Rethinking agitation management in dementia: Integrating pain assessment to reduce antipsychotic prescription

Purpose of Project: Dementia affects over 55 million individuals worldwide and is frequently complicated by agitation, a distressing neuropsychiatric symptom. Despite limited efficacy and an FDA black box warning, antipsychotic medications remain widely prescribed, exposing this vulnerable population to significant risks. Pain is highly prevalent in individuals with moderate to severe dementia but often underrecognized due to impaired communication, leading to misclassification of pain-driven behaviors as psychiatric disturbance. This quality improvement project aimed to improve pain recognition and reduce inappropriate antipsychotic prescribing through integration of the Pain Assessment in Advanced Dementia (PAINAD) tool into neuropsychiatric assessments of dementia-related agitation in the Psychiatric Emergency Department at a large urban public hospital.Methodology: Using a quasi-experimental pre–post design guided by the Plan-Do-Study-Act model, the project compared 42 pre-implementation encounters with 30 post-implementation encounters. The intervention incorporated routine PAINAD assessment into evaluations of agitation among individuals with dementia. Descriptive and comparative analyses were conducted to evaluate changes in pain recognition, antipsychotic prescribing, and analgesic use.Results: Pain assessment was documented in both groups; however, implementation of the PAINAD tool led to a significant increase in pain recognition (0% pre vs. 63% post, p < .001). Antipsychotic prescribing decreased from 69% pre-implementation to 43% post-implementation, representing a clinically meaningful reduction (p = .052). Analgesic prescribing increased from 12% pre to 33% post-implementation, reflecting improved recognition and management of pain, though this change did not reach statistical significance.Implications for Practice: Findings support the integration of structured pain assessment into psychiatric emergency workflows as a feasible, low-resource intervention that enhances person-centered care for individuals with dementia. Routine use of the PAINAD tool may reduce reliance on high-risk antipsychotic medications by improving clinicians’ ability to identify and appropriately treat pain-driven agitation.