CONSIDER: DEMENTIA
Overview
Dementia is usually known to exist prior to an older person entering the hospital. On the other hand, disruption of an older adult's normal routine may surface a previously undiagnosed dementia in the hospital.
In either situation, agitation and sometimes aggression are common and often emergent behavioral manifestations of the patient with dementia. These neuropsychiatric symptoms are also seen in patients with delirium, schizophrenia, and bipolar disorder in the presence or absence of dementia. These symptoms are not disease specific and derive from neurobiological changes in areas of the brain and are influenced by the patient's interaction with the environment.
It is not unusual for patients with dementia to also be delirious. Agitation thus may be a manifestation of dementia alone, or it may be caused or made worse by delirium. (See Delirium Topic)
Definitions
Agitation: excessive motor or verbal activity.
- Common motor examples of agitation include irritability, restlessness, resisting needed assistance, hyperactivity, pacing, wandering, assaultiveness, threatening gestures, spitting, and physical destructiveness.
- Common verbal examples of agitation include verbal abuse, belligerence, screaming, swearing, and expressions of anger.
- Try This: Mental Status Assessment of Older Adults: The Mini Cog
- Try This: The Confusion Assessment Method (CAM)
- Try This: The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)
- The Brief Psychiatric Rating Scale (BPRS) is a commonly used rating scale for agitation/aggression although the above symptoms are used as a guide in most care settings by most clinicians.
- Try This: Recognition of Dementia in Hospitalized Older Adults
- Try This: Assessing and Managing Delirium in Persons with Dementia
| Table 1. Most Likely Causes of Agitation/Agression in Individuals with Dementia: Assessment and Interventions | |
| Assessment | Intervention |
| Assess for unrelieved acute or chronic pain or discomfort Consider superimposed medical condition such as infection, electrolyte disturbance, endocrine abnormality, or hypoxia. Consider drug therapy or substance abuse |
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| Assess environmental stressors such as noise, overstimulation, understimulation, lack of structure/ predictability including during transitions in care to another setting |
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| Assess for causal or contributing interpersonal communication factors that may trigger agitation such as communication deficits (vision/hearing), fear or anxiety, and caregiver's response to the patient's behavior |
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| Recognize cues to escalating behaviors that lead to agitation and catastrophic reactions | The key to nonpharmacological intervention for episodes of agitation/aggression is to identify and avoid the triggers and contributing factors If catastrophic behavior occurs:
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References
Teri, L; Logston, R, McCurry, S. (2002). Nonpharmacological treatment of behavioral disturbance in dementia. Medical Clinics North America, 86, pp. 641-656.
Volicer, L, Hurley, A. (2003). Management of behavioral symptoms in progressive degenerative dementias. Journal of Gerontology: Medical Sciences,58A, pp. 837-845.
Allen, MH. (2000).Managing the agitated psychotic patient: a reappraisal of the evidence. Journal of Clinical Psychiatry, 61 (supplement 14), pp 11-20.
Allen, MH, Currier, GW, Hughes, DH, et al. (2001).The expert consensus guideline series: Treatment of behavioral emergencies.Postgraduate Medicine Special Report, pp. 1-88.
Last updated - April 2007
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