Neuropsychiatric symptoms are nearly universal in dementia,1 and agitation is among the most distressing for patients and caregivers. Currently no drug has clearly been shown to be of value in the treatment of agitation in dementia. The most commonly used class of drugs (antipsychotics) may be neither safe nor effective.2 3 Although antidepressants may have a better risk to benefit ratio, no sufficiently powered trials have evaluated their safety and efficacy in dementia, and only one is currently in progress.4

Patients may be unable to communicate their sensation of pain because of impaired memory or lack of expressive language. Underdiagnosed and undertreated pain has been associated with agitation in dementia.5 Thus, better pain management may decrease agitation in dementia.

To test this hypothesis, the linked randomised controlled trial by Husebo and colleagues (doi:10.1136/bmj.d4065) assessed an eight week trial of pain treatment in 253 nursing home residents with dementia and agitation.6 Treatment allocation used a cluster approach at the nursing home level because staff needed …