Agitation in Dementia

Aka: Agitation in Dementia, Dementia Related Agitation

1. See Also
   1. Dementia
   2. Dementia Management
   3. No-fail Environment in Dementia
   4. Dementia Related Malnutrition
   5. Behavior Problems in Dementia
   6. Sleep Problems in Dementia
   7. Wandering Behavior in Dementia
2. Etiology: Behavior Decompensation (The 6 I's)
   1. See Delirium
   2. Iatrogenic
      1. Anticholinergic Medications
      2. Sedative-Hypnotic Medications
   3. Infection
      1. Urinary Tract Infection
      2. Pneumonia
   4. Injury
      1. Pain is a common exacerbating factor
      2. Hip Fracture
   5. Illness exacerbation
      1. Diabetes Mellitus
      2. Chronic Obstructive Pulmonary Disease (COPD)
      3. Major Depression
   6. Impaction of feces
   7. Inconsistency in environment or routine change
   8. Other
      1. Thirst or hunger
      2. Drug or Alcohol use
      3. Caffeine
3. Approach: Catastrophic Reaction
   1. Results from Task failure
      1. Patient told that they're wrong
   2. Symptoms
      1. Irritability
      2. Accusation
      3. Tearful
      4. Combative
   3. Management: Non-Pharmacologic
      1. See No-fail Environment in Dementia
4. Approach: Reaction to physical Care
   1. Occurs particularly in Frontal LobeImpairment
      1. Patients Akinetic
      2. Patient wants to be left alone
   2. Management: Non-Pharmacologic
      1. Limit goals (e.g. bath less often)
      2. Follow strict routine at patient's best time of day
      3. Use slow gentle movements in physical care
      4. Approach patient from side or rear
      5. Reassure ("As soon as we're done, I'll stop")
5. Approach: Screaming
   1. Often no purpose
   2. Associated with non-directed agitation
   3. Cause may be multifactorial
      1. Pain
      2. Sensory deprivation
      3. Restraints
      4. Depression in Dementia
   4. Treat possible underlying causes
      1. Aggression-Specific Types/Other Causes
         1. Disinhibition
         2. Agitated depression
6. Precautions
   1. Only benefits have been in anger, aggression and paranoia
      1. No benefit in quality of life, care needs, or functional capacity
   2. Atypical Antipsychotics in older patients with Dementia are associated with a two fold increased mortality
   3. Adverse effects include QT Prolongation, aspiration risk and gait disturbance and increased fall risk
   4. References
      1. Sultzer (2008) Am J Psychiatry 165(7): 844-54
      2. Gill (2007) Ann Intern Med 146(11): 775-86
7. Management: Medications
   1. Indications
      1. Failed Behavior Modification as above
      2. Severe and refractory agitation
   2. Medication preparations
      1. Antipsychotics (all agents with similar efficacy)
         1. Old, cheap drugs with high extrapyramidal effects
            1. Haloperidol 0.5 mg PO bid ($5/month)
               1. Useful as initial agent in acute agitation
               2. Switch to agent below if need to continue
               3. Avoid in Parkinson's Disease
               4. Markedly impairs mobility secondary to rigidity
         2. New, costly drugs with low extrapyramidal effects
            1. Use caution
               1. Increased risk of death on atypical Antipsychotics
               2. Obtain baseline EKG before starting to check QT Prolongation
            2. Risperidone (Risperdal) 0.5 mg bid ($78/month)
               1. Effective on Psychosis Symptoms
               2. Side effects may limit use
            3. Quetiapine (Seroquel) 25 mg PO bid ($85/month)
               1. Preferred of the atypical Antipsychotics if comorbid Parkinson's Disease
         3. Agents to avoid
            1. Olanzapine was associated with worse functional outcomes
            2. Sultzer (2008) Am J Psychiatry 165(7): 844-54
      2. Other agents with potential benefit
         1. Divalproex (Depakote)
         2. Carbamazepine (Tegretol) titrate to 300 mg/day
            1. Limited by Sedation, narrow therapeutic window
         3. Trazodone (Desyrel) 50 mg PO qhs
         4. Selective Serotonin Reuptake Inhibitor
            1. Citalopram (Celexa)
            2. Sertraline (Zoloft)
            3. Mirtazapine (Remeron)
         5. Newer Tricyclic Antidepressants (e.g. Pamelor)
      3. Agents with only anecdotal support
         1. Beta Blockers (e.g. Propranolol)
         2. Lithium
         3. Buspirone (Buspar)
      4. Agents to use with only with caution
         1. Benzodiazepines: Lorazepam (Ativan) 0.25 - 0.50 mg
            1. Give 30 minutes prior to physical care
            2. May cause Ataxia, risk of falls
8. References
   1. Howell in Duthie (1998) Geriatrics p. 295-305
   2. Ham (1997) Postgrad Med 101(6):57-70
   3. Stewert (1995) Am Fam Physician 52(8):2311-22