sharing sensitive information, make sure youre on a federal Animal-assisted activities and therapy (AAA/AAT). The https:// ensures that you are connecting to the Tondi L, Ribani L, Bottazzi M, et al. Study enrollment was limited to subjects with few comorbidities, limiting the generalizability of study findings. A recent Cochrane review noted that patients with severe baseline symptoms at anti-psychotic initiation may experience worsening symptoms after discontinuation, and those with less severe symptoms may see no change following discontinuation. Psychotropics. The interactive relationship between pain, psychosis, and agitation in people with dementia: results from a cluster-randomised clinical trial. Defrancesco M, Marksteiner J, Fleischhacker WW, Blasko I. Briefly, non-pharmacological methods, such as patient distraction and redirection, should first be employed. Commonly overlooked causes of pain that may exacerbate agitation, Table 4. 2005;31:26-32.3. Libin A, Cohen-Mansfield J. Mania is common among patients with dementia experiencing aggression, and lithium may hold promise as a potential treatment for this manifestation of BPSD. Am J Recreation Ther. Ultimately, a trial of medication is appropriate when non-pharmacological interventions have not been effective, when patient behavior is interfering with the ability to provide care to them, when there is a safety risk to patient and/or caregiver, or if the patients behavior risks placement in an institutional setting. A 2014 review [42] noted that while some data exist for the value of carbamazepine to diminish agitation, sample sizes are small, and many patients cannot tolerate carbamazepine as older adults are more likely to experience side effects such as weight change, sedation, gait disturbance, and gastrointestinal problems. Papers of particular interest, published recently, have been highlighted as: National Library of Medicine http://www.musictherapy.org. There were no significant differences in neuropsychiatric symptoms, activities of daily living, agitation, or quality of life at 21days; however, THC was well tolerated with no difference in mild or moderate adverse events. Effects on agitation with rivastigmine patch monotherapy and combination therapy with memantine in mild to moderate Alzheimers disease: a multicenter 24-week prospective randomized open-label study (the Korean EXelon patch and combination with mEmantine comparative trial study), Increased dosage of donepezil for the management of behavioural and psychological symptoms of dementia in dementia with Lewy bodies. Treatment effects between monotherapy of donepezil versus combination with memantine for Alzheimer disease: a meta-analysis. Pharmacological treatment of neuropsychiatric symptoms in Alzheimers disease: a systematic review and meta-analysis, Differential effects of current specific treatments on behavioral and psychological symptoms in patients with Alzheimers disease: a 12-month, randomized, open-label trial. Arlington, VA: American Psychiatric Association; 2007. Agitation is differentiated from aggression, which is behavioreither physical or verbalthat is directed against an object or another person or being. Wait 1 week or longer between dosage changes, Limit to 14 mg once daily if creatinine clearance < 30 mL/min, Wait 1 week or longer between dosage changes; use 2 divided doses if > 5 mg/daily, Reduce to 5 mg twice daily if creatinine clearance < 30 mL/min. and transmitted securely. J Am Geriatr Soc. Volume 25 Issue 8 Agitation in older adults is frequently associated with multiple psychiatric and medical conditions and comorbidities. Ancoli-Israel S, Martin JL, Gehrman P, et al. Dr Kyomen reports that she is a consultant for AstraZeneca Pharmaceuticals LP, Bayer Corporation, Bristol-Meyers Squibb, Merck, Eli Lilly, Roche, GlaxoSmithKline, Novartis, UCB Pharma, Wyeth-Ayerst Laboratories, and Pfizer Inc. She has received grant/research support from Bayer Corporation, Bristol-Myers Squibb, Eli Lilly, Roche, UCB Pharma, Wyeth-Ayerst, Pfizer, Inc, NIH, the John A. Hartford Foundation, the National Institute on Aging, and the Veterans Administration. Before adding additional medications, be sure that current medication regimen is optimized, and medication discontinuation has been considered for medications with limited or no benefit, SSRI selective serotonin reuptake inhibitor, SNRI serotonin and norepinephrine reuptake inhibitor. Depending on manifestations of BPSD, low- to moderate-quality evidence supports the use of anti-depressants, anti-psychotics, or anti-epileptics in conjunction with cholinesterase inhibitors. Relaxing music at mealtime in nursing homes: effect on agitated patients with dementia. If after this, the patient is still experiencing BPSD, then the patient may need an increased dose of cholinesterase inhibitors or additional medications. A training program for managing agitation of residents in long-term care facilities: description and preliminary findings. Psychiatric conditions often associated with agitation. 2002;51:317-323.15. Agitation in elderly demented patients. Given the challenge of BPSD for patient and caregiver safety, plus quality of life, research progress in this area is needed to address the challenge of effectively treating BPSD and to improve patient quality of life and that of their caregivers. Figure 1 is a flowchart for assessment and pharmacological management of BPSD. Schneider LS, Tariot PN, Dagerman KS, et al. The consequences of BPSD are often significant for patients and caregivers, ranging from patient/caregiver injuries to emergency department visits and hospitalization or institutional placement [8, 9]. Am J Psychiatry. Anti-histamines such as diphenhydramine may be used by patients or caregivers to improve sleep, but the risks of falls and residual sleepiness as well as anti-cholinergic symptoms such as constipation and dry mouth make diphenhydramine a poor choice. A recent review proposed risperidone as a first-choice agent for agitation and aggression among dementia patients [69], whereas a Delphi panel suggested citalopram and analgesia [70]. Role of donepezil in the management of neuropsychiatric symptoms in Alzheimers disease and dementia with Lewy bodies. Even among experts, recommendations and treatment algorithms for BPSD vary. A 2015 RCT [61] evaluated tetrahydrocannabinol (THC), the active ingredient in cannabis, compared to placebo for control of aggression symptoms among 50 patients with AD, vascular, or mixed dementia, with 24 receiving THC and 26 receiving placebo. Arch Gen Psychiatry. Bohnen NI, Kaufer DI, Ivanco LS, Lopresti B, Koeppe RA, Davis JG, et al. Additionally, investigators in a clustered site study in Norwegian nursing homes [47] found that among 352 patients with moderate to severe dementia, verbal aggression, pacing, and restlessness responded to personalized pain therapy, using a combination of pregabalin, acetaminophen, buprenorphine patches, or extended-release morphine. Disclosure The contents of this article do not represent the views of the US Department of Veterans Affairs or the US Government. Overall, a narrative review found little evidence that anti-depressants improve depression in patients with dementia. Richeson NE, Neill DJ. Cortical cholinergic function is more severely affected in parkinsonian dementia than in Alzheimer disease: an in vivo positron emission tomographic study. official website and that any information you provide is encrypted J Gerontol B Psychol Sci Soc Sci. Lithium treatment for agitation in Alzheimers disease (lit-AD): clinical rationale and study design, Allopurinol for the treatment of refractory aggression: a case series. Add-on prolonged-release melatonin for cognitive function and sleep in mild to moderate Alzheimers disease: a 6-month, randomized, placebo-controlled, multicenter trial. Psychiatry Clin Neurosci. A detailed discussion of palliative sedation is beyond the scope of this review; readers are referred to recent reviews and guidelines for more information [55, 59, 60]. Evidence-based practice recommendations for working with individuals with dementia: simulated presence therapy. Anxiety and worries are associated with three or more of the following symptoms: agitation or feeling overexcited or fed up, tiredness, difficulty concentrating or memory gaps, irritability, muscle tension and sleep disorders [ 1 ]. The effect of the association between donepezil and choline alphoscerate on behavioral disturbances in Alzheimers disease: interim results of the ASCOMALVA trial. As benzodiazepines raise the risk of falls, delirium, and behavior disinhibition among patients with dementia, they are generally not recommended in this population. Before reference tool for emergency physicians, the product of whichwas the Assess, Diagnose, Evaluate, Prevent, and Treat(ADEPT) tool (Figure 1).6The ADEPT acronym stands for5 core principles that can help ensure adequate and thoroughcare for older adults with agitation or delirium: assess,diagnose, evaluate, prevent, and treat. All are off-label use for BPSD; reassess use after 4 weeks, and if no improvement with maximum dose, consider tapering and withdrawing medication. Methods This study used a descriptive qualitative methodology. ED is often a symptom of another health problem or health-related factor. These include typical and atypical antipsychotics, mood stabilizers, sedatives/hypnotics, and nootropic agents.Nonpharmacological interventionsMost of the nonpharmacological treatment interventions were developed for older adults with agitation and cognitive impairment or dementia. The United States (US) Food and Drug Administration Center for Drug Evaluation and Research has highlighted that the various definitions of agitation . Conflict of Interest Cara McDermott and David Gruenewald declare no conflict of interest. Herein, we describe an agitated geriatric patient who suffered an adverse outcome due to treatment for agitation in an emergency setting. Recent Findings We reviewed human studies published from 2013 to 2018 evaluating pharmacologic management of BPSD manifestations including depressive symptoms, mania, psychosis, and other BPSD, as well as severe agitation without determination of underlying cause. Defects in cognition, sleep-waking cycles, and psychomotor behavior result. Anxiety among older adults is a common health concern, but there . Therapeutic recreation music intervention to decrease mealtime agitation and increase food intake in older adults with dementia. Churchill M, Safaoui J, McCabe BW, Baun MM. Cochrane Database Syst Rev. Sequential drug treatment algorithm for agitation and aggression in Alzheimers and mixed dementia. Symptoms of ED include. Given the limits of neurobiological categorization, using a cholinesterase inhibitor might produce benefits in a psychotic or delusional behavior that is mediated to some degree through the dopaminergic system, or potentially have benefits on a broad range of behavioral disturbances. Brasure M, Jutkowitz E, Fuchs E, Nelson VA, Kane RA, Shippee T, et al. Efficacy and tolerability of risperidone, yokukansan, and fluvoxamine for the treatment of behavioral and psychological symptoms of dementia: a blinded, randomized trial. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. Federal government websites often end in .gov or .mil. 1 Agitation and psychosis are common among older adults with dementia, with 80% of patients presenting with . Patients receiving dextromethorphan-quinidine had significantly lower NPI agitation/aggression scores, which was the primary endpoint of the study. However, patients receiving citalopram were more likely to experience QT prolongation and worsening of cognition at 30 mg/day dosing. 2000;(2): CD001394.31. Rosenheck RA, Leslie DL, Sindelar JL, et al. Am J Alzheimers Dis Other Demen. Neal M, Briggs M. Validation therapy for dementia. Inclusion in an NLM database does not imply endorsement of, or agreement with, However, it is recommended that while working through the main pathway prescribers should avoid introducing new acetylcholinesterase inhibitors or memantine to permit assessment of the effects of . 2002;159:1225-1227.38. Study of the use of antidepressants for depression in dementia: the HTA-SADD triala multicentre, randomised, double-blind, placebo-controlled trial of the clinical effectiveness and cost-effectiveness of sertraline and mirtazapine, What is the therapeutic value of antidepressants in dementia? Although tricyclic/tetracyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be effective in the elderly, their side effect and safety profiles are suboptimal and thus are not recommended in late-life. Divalproex sodium (valproate) has been investigated as a preventative agent for BPSD. Furukawa K, Tomita N, Uematsu D, Okahara K, Shimada H, Ikeda M, et al. Efficacy of behavioral interventions for dementia caregivers. Audio presence intervention for decreasing agitation in people with dementia. Chung JC, Lai CK, Chung PM, French HP. Gerontologist. The initial assessment of agitation in patients with a known diagnosis of bipolar disorder should focus upon determining whether the agitation is due to causes beyond mania, usually 300 mg two or three times daily; smaller doses (eg, 150 mg twice daily) are used in the elderly . An anti-depressant may help decrease agitation among patients who are also exhibiting depressed mood, anxiety, or paranoia. Monitor CBC, liver, renal function while taking medication. Across all groups, investigators noted a reduction in BPSD symptoms, but higher extrapyramidal symptoms with risperidone. Am J Geriatr Psychiatry. Summary. Therapeutic level is 412 mcg/mL, Increased risk of Stevens-Johnson syndrome. J Psychosoc Nurs Ment Health Serv. We prioritized randomized clinical trials (RCT) as the highest quality of available evidence, but also included observational studies and review articles to augment available evidence as needed. Elderly patients with altered mental status, including agitation, should be presumed to have delirium until proven otherwise. Accessed May 27, 2008.9. Published 2003. A case series reported that among older adults dying with dementia in Dutch long-term care facilities, pain and agitation were the most common cause of distress, and 21% received palliative sedation before dying [56]. http://www.nivel.nl/pdf/Multi-Sensory-Stimulation-in-24-hour-dementia-care.pdf. Comparison of sertraline, venlafaxine and desipramine effects on depression, cognition and the daily living activities in Alzheimer patients, Bupropion improved apathy in behavioral variant frontotemporal dementia: a case report. Agitated behaviors and sleep disturbances in older adults with dementia have been linked to abnormal circadian rhythms caused, in part, by a lack of exposure to light. In this review, we have described the various pharmacological options to treat BPSD, focusing on literature published 2013 to 2018. Dr Kyomen is associate psychiatrist in the department of psychiatry at Mclean Hospital in Belmont, Mass, and clinical instructor in the department of psychiatry at Massachusetts General Hospital, Boston. 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