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Agitation in Dementia
Aka: Agitation in Dementia, Dementia Related Agitation- See Also
- Etiology: Behavior Decompensation (The 6 I's)
- See Delirium
- Iatrogenic
- Anticholinergic Medications
- Sedative-Hypnotic Medications
- Infection
- Injury
- Pain is a common exacerbating factor
- Hip Fracture
- Illness exacerbation
- Impaction of feces
- Inconsistency in environment or routine change
- Other
- Thirst or hunger
- Drug or Alcohol use
- Caffeine
- Approach: Catastrophic Reaction
- Results from Task failure
- Patient told that they're wrong
- Symptoms
- Irritability
- Accusation
- Tearful
- Combative
- Management: Non-Pharmacologic
- Results from Task failure
- Approach: Reaction to physical Care
- Occurs particularly in Frontal LobeImpairment
- Patients Akinetic
- Patient wants to be left alone
- Management: Non-Pharmacologic
- Limit goals (e.g. bath less often)
- Follow strict routine at patient's best time of day
- Use slow gentle movements in physical care
- Approach patient from side or rear
- Reassure ("As soon as we're done, I'll stop")
- Occurs particularly in Frontal LobeImpairment
- Approach: Screaming
- Often no purpose
- Associated with non-directed agitation
- Cause may be multifactorial
- Pain
- Sensory deprivation
- Restraints
- Depression in Dementia
- Treat possible underlying causes
- Aggression-Specific Types/Other Causes
- Disinhibition
- Agitated depression
- Aggression-Specific Types/Other Causes
- Precautions
- Only benefits have been in anger, aggression and paranoia
- No benefit in quality of life, care needs, or functional capacity
- Atypical Antipsychotics in older patients with Dementia are associated with a two fold increased mortality
- Adverse effects include QT Prolongation, aspiration risk and gait disturbance and increased fall risk
- References
- Only benefits have been in anger, aggression and paranoia
- Management: Medications
- Indications
- Failed Behavior Modification as above
- Severe and refractory agitation
- Medication preparations
- Antipsychotics (all agents with similar efficacy)
- Old, cheap drugs with high extrapyramidal effects
- Haloperidol 0.5 mg PO bid ($5/month)
- Useful as initial agent in acute agitation
- Switch to agent below if need to continue
- Avoid in Parkinson's Disease
- Markedly impairs mobility secondary to rigidity
- Haloperidol 0.5 mg PO bid ($5/month)
- New, costly drugs with low extrapyramidal effects
- Use caution
- Increased risk of death on atypical Antipsychotics
- Obtain baseline EKG before starting to check QT Prolongation
- Risperidone (Risperdal) 0.5 mg bid ($78/month)
- Effective on Psychosis Symptoms
- Side effects may limit use
- Quetiapine (Seroquel) 25 mg PO bid ($85/month)
- Preferred of the atypical Antipsychotics if comorbid Parkinson's Disease
- Use caution
- Agents to avoid
- Olanzapine was associated with worse functional outcomes
- Sultzer (2008) Am J Psychiatry 165(7): 844-54
- Old, cheap drugs with high extrapyramidal effects
- Other agents with potential benefit
- Divalproex (Depakote)
- Carbamazepine (Tegretol) titrate to 300 mg/day
- Limited by Sedation, narrow therapeutic window
- Trazodone (Desyrel) 50 mg PO qhs
- Selective Serotonin Reuptake Inhibitor
- Newer Tricyclic Antidepressants (e.g. Pamelor)
- Agents with only anecdotal support
- Beta Blockers (e.g. Propranolol)
- Lithium
- Buspirone (Buspar)
- Agents to use with only with caution
- Benzodiazepines: Lorazepam (Ativan) 0.25 - 0.50 mg
- Give 30 minutes prior to physical care
- May cause Ataxia, risk of falls
- Benzodiazepines: Lorazepam (Ativan) 0.25 - 0.50 mg
- Antipsychotics (all agents with similar efficacy)
- Indications
- References
- Howell in Duthie (1998) Geriatrics p. 295-305
- Ham (1997) Postgrad Med 101(6):57-70
- Stewert (1995) Am Fam Physician 52(8):2311-22