Agitation and Behavioral Challenges

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There is no universally accepted clinical definition of “Agitation”. At best, it's a clinical construct with billing implications.

By "agitation", we generally mean excessive motor activity, verbal aggression, or physical aggression. Sometimes called "behavioral and psychological symptoms of dementia (BPSD)", or "neuropsychiatric symptoms (NPS)". Whatever you call it, it refers to global distress; hallucinations, delusions, anger, rage, combativeness, fearfulness, tearfulness, wandering, pacing, hoarding, mood instability, and all the other symptoms of suffering that accompany cognitive disorders. 

Agitation occurs in 90% of pts with dementia. Ninety percent. So if you are fortunate enough to have a pleasantly confused peep, thank your lucky stars and donate generously to the Alzheimer’s association. For the rest of us, try this:
 

Start with a cholinesterase inhibitor (donepezil, galantamine, rivastigmine) or NMDA receptor antagonist (memantine). Hands down, the best treatment for dementia-specific behavior disturbance is a dementia-specific drug. Don’t think of them as precognition agents, or even cognitive enhancers. Think of them as useful agents for targeting dementia-related behaviors.
 

Let me say it again: The best treatment for dementia-specific behavior is a dementia-specific med. With the exception of FTLD, first line tx for BPSD is a ChEI or glutamate antagonist. Rivastigmine patch can help with dementia-related hallucinations. Memantine has a very nice anxiolytic benefit. All of them tend to be calming.

Start with Prevention

• Treat pain: Most repetitive calling out is related to pain

• Feed and water

• Reduce anticholinergics

• Optimize sleep

• Provide appropriate stimulation 

Prune the med tree. Just say NO to  diphenhydramine, promethazine, cyclobenzaprine, oxybutynin, etc. Avoid anticolinergics.

New  onset of confusion? Rule out a delirium. If you just started a med,  stop it. If you just stopped something, restart it. Check for an  infection.

Mood stabilizers can be helpful. 

Gabapentin can be useful if the  pt also has neuropathic pain that might be contributing. Carbamezapine  can also be helpful. 

New  onset of confusion? Rule out a delirium. If you just started a med,  stop it. If you just stopped something, restart it. Check for an  infection.

One of the most common culprits in agitation is akathisia from too much  neuroleptic. If your peep is squirrelly after getting haloperidol, do  not repeat the dose. Hydrate, hydrate, hydrate, and have him walk around  to burn off energy.

New  onset of confusion? Rule out a delirium. If you just started a med,  stop it. If you just stopped something, restart it. Check for an  infection.

Prazosin can help block overactive adrenaline

Carbamazepine has decent data

Depakote no longer in favor d/t encephalopathy risk, so we generally reserve it for severe aggression that places the pt and others at risk of harm.

Remember, the strongest predictor of combativeness is actually constipation. 

Poop = happy.  No poop, no happy.

Prevention, prevention, prevention. Try to prevent a melt-down the  same way you do with your family, your in-laws, and yourself when  someone cuts you off.

Avoid overstimulation. Avoid hunger and thirst. Avoid frustration.

Feed and water your soul and theirs.

Ambulate q2H while awake to burn off excess energy. Take a walk outdoors. Get some fresh air.

Adequate sleep hygiene.

There are a bazillion reasons why folks wander. Distorted memory of surroundings, disorientation, routine response to lifelong routine. If everyone puts on their coat and heads toward the door, your peep is going to head towards the door too. It’s a stimulus response. 

If you don’t want your pt to go out the door, camouflage the door. Hang a mirror on it! Now it’s not a door anymore.

Here’s a very important tidbit: Pt frequently wander because they are looking for a place to pee. If you do nothing else, putting your pt on a q2-3H toileting schedule will go a long way toward reducing wandering and agitation.

Here’s another tidbit: Pts wander because there is too much stimulation. Get rid of the clutter. Both visual clutter and auditory noise. Get rid of overly stimulating stuff. We call it Feng shui for the frontal lobe.   

New  onset of confusion? Rule out a delirium. If you just started a med,  stop it. If you just stopped something, restart it. Check for an  infection.

Most calling-out behavior has to do with pain. It doesn’t matter if  they are calling “help me, help me, help me” or “Marcia, Marcia,  Marcia.” Repetitive phrasing is almost always related to pain.

Scheduled  APAP can make a world of difference. For most elders, we recommend an  upper limit of 4000mg/day. For frail elders or those in the 90/90 club, I  stop at 3000mg/day.

Pain is undertreated in the majority of older adults, including 66% of pts in LTC.

If your pt has 80-year-old bones and muscles, they probably hurt.

If your pt falls a lot, they probably hurt.

If they have a fever, they probably hurt.

If they are immobile, they probably hurt.

If they have arthritis, they probably hurt.

Here’s some trivia: this diurnal pattern of late-afternoon agitation affects 25% of pts with amyloidopathies (eg Alzheimer’s) and 45% of pts with tauopathies (eg LBD). The literature is divided on the existence of this syndrome, but you know it when you see it.

And here’s an interesting factoid for your inner Hermione Granger: The preferred term for sundowning is “temporally related agitation.”. So there, you can look smugly at those of us that still call it sundowning.

There are numerous theories, including fatigue, changes to lighting and shadows, flurry of late-afternoon activity, disruption of circadian rhythm due to neurodegeneration. One of the more salient theories is that there is a late afternoon drop in core body temperature, and thermoregulation (body’s ability to keep itself warm) uses up 5HT, which is a precursor to serotonin.

Try maximizing sunlight during the daytime, apply a warm blanket at dusk. Try bright light therapy; some studies say it works, others say no, but it may work for your particular pt. Same with melatonin; literature is divided, but it may work for your peep.

I find that the best approach is a consistent, almost methodical routine: An afternoon walk followed by tea and a biscuit, followed by Wheel of Fortune, followed by supper, followed by music, followed by bedtime, or whatever. Keep it consistent, predictable, stable, with no unexpected surprises for the fragile frontal lobe to interpret.  

When to use lorazepam?

· Only for etoh or benzo withdrawal. Otherwise never, ever, ever.

· GABA receptors are the molecular targets for benzodiazepines, barbiturates, and alcohol, all of which share the neuropharmacological properties, cross-tolerance, and cross-dependence. Would you give your confused pt a shot of tequila? 

When should you use an antipsychotic?

· When they are psychotic. Hallucinating. Delusional. Acting on internal stimuli. Violent.

How to interpret the FDA boxed warning:

· This is the blurb I use with my peeps, and I say it almost verbatim. “When you watch TV, you will hear commercials that say ‘If your loved one has dementia and is on one of these medicines, call this law firm.’ Well, this is one of those meds. This medication has a 1.6-1.7 X increased risk of death. Suppose he has a 10% chance of having a stroke; well, this medication can increase that risk to 16 or 17%. That’s what the number means. So we use these medicines cautiously, and try to use the lowest possible dose. The best way to treat psychosis is with an antipsychotic. If the pt’s psychosis causes him to act on delusional content, leading to unsafe behaviors such as combativeness or violence, then we must treat it aggressively. Additionally, delusions cause pts to have considerable distress, which affects quality of life. In my opinion, the risks of untreated psychosis outweigh the potential risks associated with low dose antipsychotic in this vulnerable elder.”

· If the pt is also requiring restraints, I add this blurb: “We are aware of the boxed warning for cardiovascular risks associated with antipsychotic use, including increased mortality, but there are also cardiovascular risks associated with untreated psychosis and uncontrolled agitation, including hyperthermia, acidosis, rhabdomyolysis, and cardiovascular collapse. Therefore, we strongly recommended continuing low dose antipsychotic at this time, with a plan to taper it off once the patient stabilizes.” 

· In summary, if the pt is too aggressive to allow the nursing staff to get close enough to them to clean up incontinence and provide basic hygiene, then the use of a sedating med is justified. We must first and foremost act humanely and provide for basic comfort and compassion.

And finally, when to use a “sitter”:

· In my opinion, never. If you are fortunate enough to be able to afford a 1:1 supervision, then that staff member needs to be engaging with the pt, ambulating q2H to burn off excess energy, providing adequate hydration, frequent toileting, etc. There should be no sitting in “sitting”. 

· Plus, would you want a stranger sitting at your bedside 24 hrs a day if you were paranoid and suspicious?