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Agitation in DementiaAka: Dementia Related Agitation

See Also
Etiology of Behavior Decompensation (The 6 I's)
1. Iatrogenic
  1. Anticholinergic Medications
  2. Sedative-Hypnotic Medications
2. Infection
  1. Urinary Tract Infection
  2. Pneumonia
3. Injury
  1. Hip Fracture
4. Illness exacerbation
5. Impaction of feces
6. Inconsistency in environment or routine change
7. Other
  1. Thirst or hunger
  2. Drug or Alcohol use
  3. Caffeine
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
Reaction to physical Care
1. Occurs particularly in frontal lobe Impairment
  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")
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
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)
        
        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
    2. New, costly drugs with low extrapyramidal effects
      1. Risperidone (Risperdal) 0.5 mg bid ($78/month)
      2. Quetiapine (Seroquel) 25 mg PO bid ($85/month)
        
        Indicated for Parkinson's Disease
  2. Other agents with potential benefi
    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
    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
References
1. Howell in Duthie (1998) Geriatrics p. 295-305
2. Ham (1997) Postgrad Med 101(6):57
3. Stewert (1995) Am Fam Physician 52(8):2311

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 5/10/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.