Need Help Stat

CONSIDER: AGITATION & DEMENTIA

Evidence Based Nonpharmacologic Interventions for Agitation

DeAnne Zwicker MS, APRN, BC & Kathy Fletcher, MS,APRN, BC, FAAN

I. Overview

A. Behaviors in dementia may represent feelings and needs that cannot be verbalized adequately1 and may be the result of an inability to communicate needs in an unpleasant environment (temperature and noise) or physical discomfort (pain or fecal impaction).2

B. Prevalence of agitation 1

  • Over 50% in community dwelling
  • Up to 70% of nursing home residents

C. Common agitated behaviors: 3

  • Physical agitation: pacing, repetitive movements
  • Verbal agitation: screaming, complaining

II. Behavior Assessment

A. The first step is to assess and record behavior patterns4 and attempt to identify triggers, underlying cause of agitated behavior for the individual:3

B. Evaluate for environmental triggers, common medical illnesses, and concomitant medications that may be causing or exacerbating symptoms 3, 5

1. Environmental Triggers

· Room temperature

· Positioning in chair

· Noise level

2. Medications (most commonly occurring)

· New medications

· Modification of previous medications

· Newly prescribed antipsychotics

 

III. Evidence Based Behavioral Interventions in Dementia

A. Most Important: Rule out delirium which may be life threatening (Kaye, J. 2007, Level V) (See Delirium Need Help Stat) (2003 version, updated 2008).

B. Assess for unmet needs as cause3, 6

  • Pain – treat any condition that might cause pain, e.g., osteoarthritis (See Pain Topic)
  • Feeling of loneliness or isolation
  • Sensory deprivation or excess
  • Offer food and fluids
  • Bowel and bladder continence
  • Restraints – remove or use alternative method (See Physical Restraints Topic)

 

C. Intervene to meet identified needs such as: 5

· Offer food or fluids

· Treat pain or discomfort

· Maintain bowel and bladder continence

· Prompted voiding- ask patient to void at regular intervals7

· Offer extra clothing; remove extra clothing

· Support sensory ability: assess hearing aids, assistive devices, and evaluate vision needs

D. Other Interventions shown to be effective:

  • White noise via audiotapes14
  • Therapeutic Touch protocol 14
  • Decrease use of physical restraints 18 (See Physical Restraints Topic)
  • Explore the unique characteristics of each individual, e.g., work, hobbies, sense of identity 3 that my be used to reduce agitation
  • Modify environment (physical or social)

o Remove physical restraints3

o Provide individual music or other sensory stimulation3

o 1:1 social interaction3, 6, 17

o Music of person’s preference 8, 9, 10

o Simulate family presence, e.g., family audio or video tapes 11

o Bright Light exposure especially with evening and late afternoon onset, 12, 15 especially useful in “sun downing”

o Walking and light exercise 16

  • Special care units
  • One-to-one social interaction may aid in the prevention and management of agitated behaviors. 6, 17
  • Exposure to a companion animal or therapy dog 18

 

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Evidence Based Guidelines for other concerns in Dementia

Doody, R.S., Stevens, J.C., Beck, C., Dubinsky, R.M., Kaye, J.A., Gwyther, L. et al. (2001). Practice Parameter: Management of dementia: An evidence-based review. Neurology, 56, 1154- 1166.

McGonigal-Kenney ML, Schutte DL. (2004). Non-pharmacologic management of agitated behaviors in persons with Alzheimer disease and other chronic dementing conditions. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core.

 

References

1. Carlson, D.L., Fleming, K.C., Smith, G.E. Evans, J.M. (1995). Management of dementia related behvoiral disturbances: A nonpharmacologic approach. Mayo Clinic Proceedings, 70(11), 1108-1115. Level of Evidence V: Literatrure review

2. Bharani, N. & Snowden, M. (2005). Evidence-based interventions for nursing home residents with dementia-related behavioral symptoms. Psychiatric Clinics ofNorth America, 28, 985-1005. Level of Evidence I: Systematic Review.

3. Cohen-Mansfield, J., Libin, A., Marcia, S., Marx, M.S. (2007). Nonpharmacological treatment of agitation: a controlled trial of systematic individualized intervention. The Journals of Gerontology, 62A(8), 908-917. Level of Evidence II: RCT

4. Cohen-Mansfield, J. (2000). Approaches to the management of disruptive behaviors. In M.P. Lawton & R.L. Rubinstein (Eds.), Interventions in dementia care: Toward improving quality of life (pp. 39-63). New York: Springer. Level of Evidence V: Literatrure review.

5. Leger, J. M., Moulias, R., Robert, P., Vellas, B., Chapuy, P. H. et al. (2002) Agitation and aggressiveness among the elderly population living in nursing or retirement homes in France. International Psychogeriatics, 14, 405-416. Level of Evidence II: Single Experimental Study.

6. Cohen-Mansfield, J. (1996). Conceptualization of agitation: Results based on the Cohen-Mansfield Agitation Inventory and the agitation behavior mapping instrument. International Psychogeriatrics; 8 (Suppl 3), 309-15.

7. Schnelle, J.F., Newman, D., White, M., Abbey, J.,Wallston, K.A., Fogarty, T., & Ory, M.G. (1993). Maintaining continence in nursing home residents through the application of industrial quality control. The Gerontologist, 33(1), 114-121. Level of Evidence II: Single Experimental Study.

8. Gerdner,L.A.(2000). Effects of individualized versus classical “relaxation” music on the frequency of agitation in elderly persons with Alheimer’s disease and related disorders. International psychogeriartcs, 12, 49-65. Level of Evidence II: Single Experiemental Study.

9. Tabloski, P., McKinnon-Howe, L., Remintgton, R. (1995). Effects of calming music on level of agitaiton in congnitively impaired nursing home residents. American Journal of Alzheimrs Care Related Disorderers & Research, 10-15. Level of Evidence IV: Nonexperimental Study.

10. Ragneskog H, Asplund K, Kihlgren M, Norberg A.(2001). Individualized music played for agitated patients with dementia: analysis of video-recorded sessions. International Jorunal of Nursing Practice,7(3), 146-55. Level of Evidence IV: Nonexperimental Study.

11. Camberg, L., Woods, P., Ooi, (1999). Evaluation of simulated presence to enhance well-being in persons with Alzheimer’s disease. Journal of the American Geriatrics Society, 47(4), 446-52. Level of Evidence II: Single Experimental Study.

12. Lyketsos, C., Lindell-Veisel, L., Baker, A., & Steele, C. (1999). A randomized controlled trail of bright light therapy for agitated behaviors in dementia patients residing in long-term care. International Journal of Geriatric Psychiatry, 14(7), 520-525. Level of Evidence II: RCT.

13. Burgio L., Scilley, K., Hardin J.M., Hsu, C., Yancey, J. (1996). Environmental "white noise": An intervention for verbally agitated nursing home residents. Journals of Gerontology A: Biological Sciences & Medical Ssciences, 51(6), P364-73. Level of Evidence II: Single Experimental Study.

14. Woods DL, Dimond M. (2002). The effect of therapeutic touch on agitated behavior and cortisol in persons with Alzheimer's disease. Biological Research for Nursing, 4(2):104-14. Level of Evidence IV: Nonexperimental Study.

15. Lovell, B.B., Ancoli-Israel, S., & Gervitz, R. (1995). Effect of bright light treatment on agitated behavior in institutionalized elderly subjects. Psychiatric Research, 57, 7-12. Level of Evidence II: Single Experimental Study.

16. Holmberg, S.K. (1997). Evaluation of a clinical intervention for wanderers on a geriatric nursing unit. Archives of Psychiatric Nursing, 11(1):21-8.

17. Draper B, Snowdon J, Meares S, Turner J, Gonski P, McMinn B, McIntosh H, Latham L, Draper D, Luscombe G. (2000). Case-controlled study of nursing home residents referred for treatment of vocally disruptive behavior. International Psychogeriatrics, 12(3), 333-44. Level of evidence II: Single Experimental Study.

18. Evans, D., Wood, J., & Lambert, L. (2002). A review of physical restraint minimization in the acute and residential care settings. Journal of Advanced Nursing, 40(6), 616-625. Level of Evidence V: Review

19. Churchill M, Safaoui J, McCabe BW, Baun MM. Using a therapy dog to alleviate the agitation and desocialization of people with Alzheimer's disease. Journal of Psychosocial Nursing and Mental Health Services, 37(4), 16-22. Level of Evidence IV: Nonexperimental Study

Last updated - March 2009