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CONSIDER: DEMENTIA

DeAnne Zwicker MS, APRN, BC

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.

 

 

 

 

 

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



Assess environmental stressors such as noise, overstimulation, understimulation, lack of structure/ predictability including during transitions in care to another setting
  • Increase or decrease the stimuli (light, noise, temperature, number of care providers, roommate considerations) as appropriate.
  • Provide an unambiguous environment (simplify care, remove clutter)
  • Plan for appropriate sleep/rest periods
  • Anticipate patient's needs for care in current setting and during care transition and plan accordingly.
  • Plan for stimulating activity as appropriate (physical, occupational, music, art, dance, exercise, recreational therapy)
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
  • Identify and correct sensory impairments
  • Encourage self care and patients active participation in the care
  • Provide anxiety-reducing techniques by using a calm manner and touch. Consider massage, warm baths, and/or soothing music or comfort foods
  • Avoid the use of force/physical restraint
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:
  • Get help immediately if there is imminent danger to the patient or others
  • Stay calm-avoid arguing, disagreeing, or forcing the patient
  • Calm and reassure the patient
  • Provide unconditional respect/regard
  • Redirect/refocus the patient
  • Give simple commands preferably from a single trusted care provider
  • Provide a quiet/secure environment
  • Avoid unnecessary stimulation
  • Check for and eliminate stressors
  • Restrain (physically/chemical sedation) as a last resort and in the least restrictive manner
  • Provide vigilant monitoring and evaluation

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 - March 2009