Assessing and managing agitation associated with Alzheimer’s dementia

Agitation is common among patients with Alzheimer’s disease (AD) and results in a range of behavioral disturbances that increase the caregiver stress and the risk of placement in long-term care. However, careful assessment of the agitation in terms of behaviors, consequences, motivations, and functions, together with determination of the potential causes, can enable effective management strategies. Marc Agronin, Senior Vice President for Behavioral Health, Miami Jewish Health, Miami, Florida, described how this can be achieved using a detective-like approach at Psych Congress 2019.

Agitation is a common behavioral and psychological symptom of dementia (BPSD)

According to the International Psychogeriatric Association, agitation involves excessive motor activity, or verbal or physical aggression that causes observed (or inferred) emotional distress and is severe enough to produce excess disability and significant impairment in interpersonal relationships, social functioning, and the ability to perform or participate in daily living activities,1 said Dr Agronin.

Neurodegenerative-associated metabolic changes in the cholinergic, serotoninergic and dopaminergic neurotransmitter systems compound the agitation

The neurodegenerative process of AD damages the neurocircuitry in patients with AD. The resulting difficulties in responding appropriately to emotionally laden events and in prioritizing, organizing, and responding to challenges (executive function), leads to agitation, explained Dr Agronin. Neurodegenerative-associated metabolic changes in the cholinergic, serotoninergic and dopaminergic neurotransmitter systems compound the agitation.

A detective-like approach is required to assess agitation

Agitation can be triggered by many factors, in particular medical and psychiatric illnesses, medications (potentially inappropriate prescriptions), and psychological and environmental factors. A detective-like approach is required to determine the precise cause of any particular agitation-related behavior, explained Dr Agronin.

A detective-like approach is required to determine the precise cause of any particular agitation-related behavior

A full physical, neurological and mental state examination, together with blood tests and appropriate imaging will detect any contributory physical or psychiatric triggers, while an Applied Behavior Analysis (ABA)2 can be used to reveal psychological and environmental factors.

People do not randomly become agitated, said Dr Agronin. The agitation serves a function, and it is necessary to determine the function to guide appropriate management.

The ABA model can be used to examine the context in which agitation occurs and the five main functions of the agitation behavior — pain attenuation, attention, stimulation, tangibles (e.g., food), and escape (e.g., from unpleasant situations).

Agitation serves a function

Behavioral management

Dr Agronin highlighted the importance of basic behavioral approaches to address an individual’s specific triggers, behaviors, consequences of the behavior, motivations, and function, to decrease the frequency and severity of agitation. Such behavioral approaches include:

  • empathic acknowledgement with active listening
  • addressing unmet needs; such as hunger, thirst,  pain and environmental irritants, such as excessive noise, heat or cold
  • a focus on abilities instead of deficits
  • engaging the family and other familial caregivers
  • involvement in stimulating, pleasant activities3

Pharmacologic management

Medications may be needed to manage severe behaviors, underlying psychiatric disorders, and associated psychotic symptoms, and also when behavioral approaches fail, said Dr Agronin.

However, there is no universally recognized or FDA-designated indication for agitation in dementia, and all psychotropic medication is therefore “off-label.”

In addition, there is no single magic bullet, said Dr Agronin — efficacy is limited and variable, and potentially important adverse events (AEs) include sedation, dizziness, and blood pressure changes. Continual monitoring and reassessment are necessary to ensure an appropriate risk–benefit balance for the patient.

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References
  1. Cummings J, et al. Int Psychogeriatr. 2015;27:7–17.
  2. LeBlanc LA, et al. Behavioral gerontology. In: Fisher WN, et al (Eds). Handbook of Applied Behavior Analysis. New York, NY: Guilford Press;2011:472–86.
  3. Cohen-Mansfield J, et al. J Gerontol A Biol Sci Med Sci. 2007;62:908–16.
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