II. Pathophysiology

  1. As Dementia progresses, behavior replaces language as the primary communication medium

III. Etiology: Behavior Decompensation (The 6 I's)

  1. See Delirium
  2. Iatrogenic
    1. Anticholinergic Medications
    2. Sedative-Hypnotic Medications
  3. Infection
    1. Urinary Tract Infection
    2. Pneumonia
  4. Injury
    1. Pain is a common exacerbating factor
    2. Hip Fracture
  5. Illness exacerbation
    1. Diabetes Mellitus
    2. Chronic Obstructive Pulmonary Disease (COPD)
    3. Major Depression
  6. Impaction of feces
  7. Inconsistency in environment or routine change
  8. Other
    1. Thirst or hunger
    2. Drug or Alcohol use
    3. Caffeine

IV. Approach: General

  1. Excluding medical causes is critical (see above)
  2. Ask care givers which they believe is likely causative (see list below)
  3. Cohen-Mansfield Agitation Inventory (CMAI)
    1. http://www.dementia-assessment.com.au/symptoms/CMAI_Scale.pdf
    2. Distinguishes between the four general categories above to help direct management
    3. Can be used to monitor for treatment efficacy
  4. Categories of behavior changes causes
    1. Psychosis
      1. Presents with Delusions or Hallucinations
      2. Fear and distress from Psychosis responds to Atypical Antipsychotics (e.g. Risperidone, Quetiapine)
      3. Avoid Antipsychotics (except Quetiapine) in Lewy Body Dementia (paradoxically worsen)
      4. Avoid Antipsychotics as Chemical Restraint only
    2. Mood
      1. Presents with dysphoria, screaming
      2. Consider Cornell Scale for depression assessment in Dementia
      3. Non-pharmacologic therapy is most effective
      4. Consider Bupropion or Methylphenidate to assist with withdrawn patients
      5. Consider ECT for severely withdrawn or disruptive behaviors
      6. Consider Mirtazapine for suppressed appetite
    3. Physical behaviors (overstimulation response)
      1. Presents with hitting or other Violent Behaviors
      2. Always consider pain as an underlying cause of physical behaviors
      3. Consider Olanzapine (Zyprexa, Zydis) dissolvable tablet as needed for Violent Behaviors
      4. Avoid Benzodiazepines (due to paradoxical worsening)
    4. Disinhibition (understimulation response)
      1. Presents with calling for help, ruminating, voiding in wrong place...
      2. Reorientation activities may help
  5. References
    1. Tung (2012) Mayo POIM Conference, Rochester

V. Approach: 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

VI. Approach: Reaction to physical Care

  1. Occurs particularly in Frontal LobeImpairment
    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")

VII. Approach: 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

VIII. Precautions

  1. Antipsychotics only demonstrate benefit in anger, aggression and paranoia
    1. No benefit in quality of life, care needs, or functional capacity
  2. Atypical Antipsychotics have serious, including life-threatening side-effects
    1. Atypical Antipsychotics in older patients with Dementia are associated with a two fold increased mortality
    2. Adverse effects include QT Prolongation, aspiration risk and gait disturbance and increased fall risk
  3. Obtain Informed Consent before starting
    1. Medication risks and benefits should be reviewed with patients and their care Caregivers before starting
  4. Avoid using newer agents without proven efficacy and longterm safety (and very expensive)
    1. Example: Nuedexta (Dextromethorphan/Quinidine) - NMDA Receptor Blocker
    2. (2017) Presc Lett 24(6): 33
  5. References
    1. Sultzer (2008) Am J Psychiatry 165(7): 844-54 [PubMed]
    2. Gill (2007) Ann Intern Med 146(11): 775-86 [PubMed]

IX. Management: Medications

  1. Indications
    1. Failed Behavior Modification as above
    2. Severe and refractory Agitation
  2. Medication preparations
    1. Approach
      1. Start dosing at one third to one half of typical starting dose
      2. Titrate slowly and taper off if no effect within first 4 weeks
      3. Even if effective, attempt to taper after 4 months (often can taper without relapse)
    2. Antipsychotics (all agents with similar efficacy)
      1. New, costly drugs with low Extrapyramidal Effects (but overall preferred by geriatricians)
        1. Use caution
          1. Increased risk of death on Atypical Antipsychotics
          2. Obtain baseline EKG before starting to check QT Prolongation
        2. Aripiprazole (Abilify)
          1. Consistently effective with small reductions in adverse behaviors
          2. Lower daily doses (<10 mg) are effective
          3. Increased CV and CVA risk, but unknown effect on mortality
        3. Risperidone (Risperdal) 0.5 mg bid ($78/month)
          1. Effective on Psychosis Symptoms
          2. Side effects may limit use
          3. As with Quetiapine and Olanzapine, had a 3.5% absolute increase in mortality
        4. Quetiapine (Seroquel) 25 mg PO bid ($85/month)
          1. Preferred of the Atypical Antipsychotics in Parkinson's Disease, Lewy Body Dementia
          2. As with Risperdal and Olanzapine, had a 3.5% absolute increase in mortality
      2. Old, cheap drugs with high Extrapyramidal Effects
        1. Haloperidol 0.5 mg PO bid ($5/month)
          1. Useful as initial agent in acute Agitation
          2. Switch to agent below if need to continue
          3. Avoid in Parkinson's Disease
          4. Markedly impairs mobility secondary to rigidity
      3. Agents to avoid due to low efficacy
        1. Olanzapine (Zyprexa) was associated with worse functional outcomes
          1. Sultzer (2008) Am J Psychiatry 165(7): 844-54 [PubMed]
        2. Ziprasidone (Geodon)
        3. Paliperidone (Invega)
        4. Clozapine (Clozaril)
        5. Asenapine (Saphris)
        6. Iloperidone (Fanapt)
    3. Other agents with potential benefit
      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
        1. Escitalopram (Lexapro)
          1. Preferred over Celexa with generic status in 2012 and no known QT Prolongation
        2. Sertraline (Zoloft)
        3. Mirtazapine (Remeron)
      5. Miscellaneous Antidepressants
        1. Bupropion
      6. Newer Tricyclic Antidepressants (e.g. Pamelor)
    4. Agents with only anecdotal support
      1. Beta Blockers (e.g. Propranolol)
      2. Lithium
      3. Buspirone (Buspar)
    5. 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, Delirium and paradoxical worsening

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