Agitation in older adults

/Home/Alzheimer's Symptoms/Alzheimer's and Agitation

Agitation in older adults is frequently associated with multiple psychiatric and medical conditions and comorbidities. It commonly occurs in patients with anxiety, affective illness, psychosis, dementia, stroke, brain injury, delirium, or pain, and in those who misuse psychoactive medications or other substances. Optimal treatment strategies to reduce or prevent agitation in older adults encompass a multidisciplinary model that used nonpharmacological and pharmacological/somatic approaches. In this article, we discuss clinical approaches for evaluating and managing agitation in older adults.

Kyomen HH, Whitfield TH. Agitation in older adults. Psychiatric Times 2008; 25(8)



Defining and determining the causes of agitation

To focus treatments appropriately, it is important to specifically define the target signs or symptoms that are being labeled as “agitation.” Agitation is a nonspecific concept that broadly encompasses various activity disturbances such as those delineated in Table 1.


________
Table 1. Types of activity disturbances often referred to as agitation in the elderly

- Purposeless hyperactivity (intrusive pacing or restless repetitive demands and behaviors)
- Wandering away from home or other protected environments
- Exhibiting socially and functionally inappropriate or aggressive behaviors (eg, disinhibited screaming, grabbing, throwing sexual advances, or suicidal gestures)
- Resistance to care (such as combativeness with personal or other nursing care; refusal of needed medications, fod, or fluids; or declining to participate in necessary diagnostic procedures, such as blood draws, urine collection, or radiological studies)
- Sleep-wake cycle disturbances
________


Specifying the actual behavior is especially important so that all treatment team members can be consistent in their understanding and subsequent approach to and treatment of the patient. For example, it is difficult to devise an effective treatment plan for agitation if some staff members refer to a patient’s combativeness as agitation, and other staff members use the term agitation to describe the same patient’s hypersexual behaviors. If each type of agitation is defined, a focused plan to manage, monitor, and evaluate the progress of each unique behavior can be developed.

Once the behavioral target signs and symptoms are identified, the next step is to determine their causes in order to formulate appropriate multidisciplinary interventions. A clinically relevant way to categorize causes is to first identify the circumstances antecedent to the behavioral target signs and symptoms that trigger the agitation and then to identify the illnesses or pathological conditions that exacerbate the agitation.

Nonpharmacological interventions are often effective for managing agitated behaviors that stem from such antecedent triggers. The solution is to develop an appropriately stimulating environment, remove or limit exposure to noxious stimuli, and provide the patient with basic nutritional and personal needs. Table 2 describes the circumstances that may trigger agitation.


________
Table 2. Circumstances antecedent to episodes of agitation

An environment with inappropriate levels of stimulation

Overstimulation
- Does the patient have a roommate who intrudes into the patient's personal space excessively?
- Is the patient's space overly noisy because of equipment (such as oxygen concentrators or ventilators) or individuals who call out incessantly?
- Are staff members rushing in and out of the patient's area as they change shifts?

Understimulation
- Is the patient occupied with appropriately challenging tasks that encourage interest and a sense of mastery?
- Is the patient exposed to adequate amounts of sensorimotor stimulation?
- Are the day programming, activities, and structure appropriate to the patient''s funcitonal capabilities?


The presence of people or objects that trigger stressful memories, drives, or feelings
- Does the patient believe that a family member is responsible for the patient's placement in an extended-care facility?
- Does the patient think that a friend who comes to visit at the hospital is able to take him or her home?
- Is the patient troubled by a roll belt or other safety restraint?

The need to eat, drink, use the lavatory, use glasses or hearing aids
- Is the patient hungry or thirsty?
- Does the patient need to b oriented to the facilities or be toileted?
- Does the patient need glasses, hearing aids, or similar sensory enhancers?
________


Various nonpharmacological therapies have been developed to provide patients with appropriately stimulating environments and to help redirect the patient and manage the setting to minimize events that can trigger agitation. These include music therapy, animal-assisted activities and therapy, touch/massage therapy, simulated presence therapy, light therapy, multisensory stimulation, validation group therapy, and skills training and behavioral-milieu management.

Psychiatric disorders (such as anxiety, mania, depression, psychosis, and dementia) and somatic conditions (such as stroke, brain injury, delirium, pain, discomfort, and adverse effects of medications) have all been implicated in exacerbating agitation. Common disorders, separately or in combination, that may co-occur with psychiatric conditions and cause acute pain and discomfort, and may contribute to delirium, are listed in Table 3. These conditions are more likely to contribute to agitated behaviors in patients with underlying dementia, partly because such persons have an impaired ability to obtain help for pain or discomfort through coherent conversation.


________
Table 3. Commonly overlooked causes of pain and discomfort that may exacerbate agitation in the elderly

Arthiritis
Constipation
Diarrhea
Urinary tract infections
Vaginal yeast infections
Decubitus ulcer
Tinea
Gastroesophageal reflux disease
Headaches
Muscle aches
Dental problems
Podiatric conditions
Low vision
Hearing loss
________


Common disorders (eg, arthritis, hearing loss) are often overlooked because of their chronic nature or because of difficulties in the patient evaluation (eg, difficulty of obtaining a clean-catch urine specimen for cultures and sensitivities from a resistant patient). Iatrogenic causes, such as diuretics given at bedtime rather than early in the day, a rebound effect from a sedative or hypnotic dose reduction or discontinuation, and paradoxical disinhibiting reactions from benzodiazepine use can also exacerbate agitation.

Thorough evaluation of the patient’s physical condition is essential so that agitation exacerbated by such disorders is not mistakenly attributed entirely to psychiatric illness and treated primarily with psychotropic medication. Table 4 presents some psychiatric conditions that may contribute to agitation.


________
Table 4. Psychiatric conditions often associated with agitation in the elderly

Psychosis (paranoia, hallucinations)
Affective illness (especially mania)
Anxiety
Delirium
Psychotic or mood disorder related to a general medical condition
Dementia
________


When it is judged that the patient’s agitation is primarily caused by psychiatric illness, it is important to determine which psychiatric conditions, signs, or symptoms are dominant and to treat accordingly with psychotropic medications. These include typical and atypical antipsychotics, mood stabilizers, sedatives/hypnotics, and nootropic agents.

Nonpharmacological interventions

Most of the nonpharmacological treatment interventions were developed for older adults with agitation and cognitive impairment or dementia. A great deal of research is still needed to evaluate these therapies more fully in combination with other therapies and in comparison with placebo or other active treatments.

Music therapy is the “clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”1 Although music therapy reduces overall agitation to a greater degree than no intervention, individualized or preferred music seems to offer greater benefit than general calming or “relaxation” music in patients with dementia.2-6 The long-term benefits of this intervention remain unclear; one study found short-term improvements in agitation but no significant differences in outcomes between music therapy and standard nursing home care groups over the course of a year.7

Animal-assisted activities and therapy use animals to encourage patient well-being, socialization, and mental and sensorimotor stimulation.8 Animal-assisted therapy with dogs was found to decrease agitated behaviors and enhance socialization in patients with dementia.9-11 A preliminary study showed that interacting with a therapeutic robotic cat decreased agitation and increased pleasure and interest in nursing home residents with dementia.12 Although the effects of animal-assisted activities and therapy on agitated behaviors in the elderly are promising, the duration of beneficial effect, the relative benefits of dogs residing on a special care unit for patients with Alzheimer disease versus visiting the patients, and the confounding effects of animals on caregivers are unclear.9

Preliminary studies suggest that tender touch, hand, and slow-stroke massage may help reduce agitation and improve well-being in older adults with dementia.4,13-16 Although limited, the available information is in favor of touch and massage therapy for behavioral disturbances in patients with dementia; however, definitive evidence about their benefits and adverse effects is lacking.17

Simulated presence therapy is an individualized therapy that uses voice recordings to suggest the presence of meaningful persons and evoke associated positive emotional experiences in patients with memory loss. Simulated presence therapy seems to decrease overall agitation and withdrawn behavior in patients with dementia, but the number and quality of studies evaluating this therapy are limited.18-20 One recent small study compared simulated family presence therapy with preferred music therapy and found that both were effective in reducing the frequency of physical agitation, that simulated presence but not preferred music decreased the frequency of verbal agitation, and that although behavioral incidents fell by one-half or more in many patients, others became more agitated.21

Light therapy uses time-limited, daytime-specific exposure to daylight, certain wavelengths of light, or full-spectrum light to treat various conditions including depression, seasonal affective disorder, and sleep disturbances. 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. Light therapy has been used to treat disruptive behaviors in dementia patients with variable short-term success, and it may be more effective in those with milder dementia.22-25

Multisensory stimulation or Snoezelen is an approach that “actively stimulates the senses of hearing, touch, vision, and smell in a resident-oriented, nonthreatening environment. It is intended to provide individualized, gentle sensory stimulation without the need for higher cognitive processes, such as memory or learning, in order to achieve or maintain a state of well-being.”26,27When integrated as part of 24-hour care in nursing home residents with dementia, it was found to be effective in reducing agitated behaviors over an 18-month period.26,28 However, a session-based Snoezelen program did not show any effects on behavior disturbances during or just after the sessions or at a 1-month postintervention evaluation.29

Validation therapy was developed for the elderly with cognitive impairments and is based on the concept of validation, the acceptance of the patient’s reality and personal experience. Preliminary studies suggest that validation therapy helps decrease behavioral disturbances and depression in older adults with dementia.30 A recent case-control study suggests that validation therapy reduces the severity and frequency of behavioral and psychological symptoms of dementia.31 However, there is inadequate evidence from randomized trials to allow definitive conclusions about the efficacy of validation therapy.30

Behavioral and milieu management skills for caregivers emphasize respectful redirection, positive expressions of concern, and an appropriate approach to the patient. Such programs have been shown to effectively reduce patient agitation.32-34 When compared to information and support-oriented interventions for caregivers, skill-building interventions reduced caregiver emotional distress more over 18 months.35 The available data suggest that caregiver-skills training may be an effective way to prevent and reduce agitated behaviors in elderly patients and improve the caregivers’ sense of mastery while decreasing stress.

Pharmacological interventions

When nonpharmacological strategies fail to effectively manage agitation, pharmacological treatment may be indicated. If there are clear psychiatric conditions and target symptoms that accompany the agitation patients are likely to be responsive to psychotropic medication. Benefit-to-risk ratio should be evaluated in choosing pharmacological interventions, and informed consent from the patient and/or legal surrogate should be obtained and documented.

Agitated behaviors have been commonly treated with typical and atypical antipsychotics, mood stabilizers, sedative/hypnotics, and/or nootropic agents; other pharmacological interventions include serotonergic agents, b-adrenergic blockers, and hormonal therapies.36,37Antipsychotics are the best studied and have been shown to modestly impact agitation. However, recent studies have questioned their effectiveness and demonstrated an increased risk of death with the use of both typical and atypical antipsychotics.

Current FDA black box warnings that caution against the use of atypical antipsychotics in older patients, especially those with dementia, may have diminished the enthusiasm for their use, even in patients who exhibit clear psychotic signs and symptoms in addition to agitation.38-41 The use of nootropic agents, promoted as a first-line treatment for agitation in dementia, also came under greater scrutiny as recent evidence showed limited efficacy of donepezil for the treatment of agitation in patients with Alzheimer disease.42

There is little evidence for the efficacy of anticonvulsants, lithium, or b-blockers for treating agitation in dementia. Because these medications have significant adverse effects, they are not recommended except for patients in whom other treatments have failed.43 Trazodone and serotonergic agents have not been well studied, except for treatment of depression. However, they may be appropriate for nonpsychotic, mildly agitated patients.43 Benzodiazepines may be helpful, as needed, for agitation. Those with short half-lives and no active metabolites, such as lorazepam or oxazepam, are preferred.43

In the light of limited evidence-based literature to support the use of psychotropic medications in the treatment of agitation, the decision about which medication to use should be determined largely by the patient’s unique needs and characteristics, the adverse-effect profile of the medication, and the benefit-to-risk ratio of treating versus not treating with a given medication.43

Conclusions

Agitation in older adults is a complex syndrome associated with multiple psychiatric and medical conditions and comorbidities. Despite its impact on elderly patients, caregivers, and health care costs, there is much that is unclear about the causes, prevention, and treatment of agitation. Yet, clinical interventions that use individualized, multidisciplinary best-practice approaches are routine. Further investigation to develop new interventions and more rigorously test existing ones is needed.

Evidence-Based References

•Ayalon L, Gum AM, Feliciano L, et al. Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Arch Intern Med. 2006;166:2182-2188.
•Kozman MN, Wattis J, Curran S. Pharmacological management of behavioural and psychological disturbance in dementia. Hum Psychopharmacol Clin Exp. 2006;21:1-12.


References

1. American Music Therapy Association. What is music therapy? http://www.musictherapy.org. Accessed May 27, 2008.
2. Hicks-Moore SL. Relaxing music at mealtime in nursing homes: effect on agitated patients with dementia. J Gerontol Nurs. 2005;31:26-32.
3. Richeson NE, Neill DJ. Therapeutic recreation music intervention to decrease mealtime agitation and increase food intake in older adults with dementia. Am J Recreation Ther. 2004;3:37-41.
4. Remington R. Calming music and hand massage with agitated elderly. Nurs Res. 2002;51:317-323.
5. Sung H, Chang AM. Use of preferred music to decrease agitated behaviours in older people with dementia: a review of the literature. J Clin Nurs. 2005; 14:1133-1140.
6. Gerdner LA. Use of individualized music by trained staff and family: translating research into practice. J Gerontol Nurs. 2005;31:22-30.
7. Ledger AJ, Baker FA. An investigation of long-term effects of group music therapy on agitation levels of people with Alzheimer’s disease. Aging Ment Health. 2007;11:330-338.
8. Delta Society. Animal-assisted activities and therapy (AAA/AAT). http://www.deltasociety.org/AnimalsAAAAbout.htm. Accessed May 27, 2008.
9. Filan SL, Llewellyn-Jones RH. Animal-assisted therapy for dementia: a review of the literature. Int Psychogeriatr. 2006;18:597-611.
10. McCabe BW, Baun MM, Speich D, Agrawal S. Resident dog in the Alzheimer’s special care unit. West J Nurs Res. 2002;24:684-696.
11. Churchill M, Safaoui J, McCabe BW, Baun MM. Using a therapy dog to alleviate the agitation and desocialization of people with Alzheimer’s disease. J Psychosoc Nurs Ment Health Serv. 1999;37:16-22.
12. Libin A, Cohen-Mansfield J. Therapeutic robocat for nursing home residents with dementia: preliminary inquiry. Am J Alzheimers Dis Other Demen. 2004;19:111-116.
13. Sansone P, Schmitt L. Providing tender touch massage to elderly nursing home residents: a demonstration project. Geriatr Nurs. 2000;21:303-308.
14. Remington R. Calming music and hand massage with agitated elderly. Nurs Res. 2002;51:317-323.
15. Snyder M, Egan EC, Burns KR. Efficacy of hand massage in decreasing agitation behaviors associated with care activities in persons with dementia. Geriatr Nurs. 1995;16:60-63.
16. Rowe M, Alfred D. The effectiveness of slow-stroke massage in diffusing agitated behaviors in individuals with Alzheimer’s disease. J Gerontol Nurs. 1999;25:22-34.
17. Viggo Hansen N, J¿rgensen T, ¯rtenblad L. Massage and touch for dementia. Cochrane Database Syst Rev. 2006;(4):CD004989.
18. Bayles KA, Kim E, Chapman SB, et al. Evidence-based practice recommendations for working with individuals with dementia: simulated presence therapy. J Med Speech Lang Pathol. 2006;14:13-21.
19. Miller S, Vermeersch PE, Bohan K, et al. Audio presence intervention for decreasing agitation in people with dementia. Geriatr Nurs. 2001;22:66-70.
20. Camberg L, Woods P, Ooi WL, et al. Evaluation of simulated presence: a personalized approach to enhance well-being in persons with Alzheimer’s disease. J Am Geriatr Soc. 1999;47:492-493.
21. Garland K, Beer E, Eppingstall B, et al. Comparison of two treatments of agitated behavior in nursing home residents with dementia: simulated family presence and preferred music. Am J Geriatr Psychiatry. 2007;15:514-521.
22. Dowling GA, Graf CL, Hubbard EM, et al. Light treatment for neuropsychiatric behaviors in Alzheimer’s disease. West J Nurs Res. 2007;29:961-975.
23. Ayalon L, Gum AM, Feliciano L, et al. Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Arch Intern Med. 2006;166:2182-2188.
24. Skjerve A, Holsten F, Aarsland D, et al. Improvement in behavioral symptoms and advance of activity acrophase after short-term bright light treatment in severe dementia. Psychiatry Clin Neurosci. 2004;58: 343-347.
25. Ancoli-Israel S, Martin JL, Gehrman P, et al. Effect of light on agitation in institutionalized patients with severe Alzheimer disease. Am J Geriatr Psychiatry. 2003;11:194-203.
26. van Weert JC. Multi-sensory stimulation in 24-hour dementia care. http://www.nivel.nl/pdf/Multi-Sensory-Stimulation-in-24-hour-dementia-care.pdf. Published 2003. Accessed June 2, 2008.
27. Kok W, Pater J, Choufour J. Snoezelen. Amsterdam: Bernardus Expertisecentrum/Fontis; 2000.
28. van Weert JC, van Dulmen AM, Spreeuwenberg PM, et al. Behavioral and mood effects of Snoezelen integrated into 24-hour dementia care. J Am Geriatr Soc. 2005;53:24-33.
29. Chung JC, Lai CK, Chung PM, French HP. Snoezelen for dementia. Cochrane Database Syst Rev. 2002; (4):CD003152.
30. Neal M, Briggs M. Validation therapy for dementia. Cochrane Database Syst Rev. 2000;(2): CD001394.
31. Tondi L, Ribani L, Bottazzi M, et al. Validation therapy (VT) in nursing home: a case-control study. Arch Gerontol Geriatr. 2007;44(suppl 1):407-411.
32. Landreville P, Dicaire L, Verreault R, et al. A training program for managing agitation of residents in long-term care facilities: description and preliminary findings. J Gerontol Nurs. 2005;31:34-42.
33. Roth DL, Stevens AB, Burgio LD, et al. Timed-event sequential analysis of agitation in nursing home residents during personal care interactions with nursing assistants. J Gerontol B Psychol Sci Soc Sci. 2002;57: 461-468.
34. Burgio LD, Stevens A, Burgio KL, et al. Teaching and maintaining behavior management skills in the nursing home. Gerontologist. 2002;42:487-496.
35. Farran CJ, Gilley DW, McCann JJ, et al. Efficacy of behavioral interventions for dementia caregivers. West J Nurs Res. 2007;29:944-960.
36. Kozman MN, Wattis J, Curran S. Pharmacological management of behavioural and psychological disturbance in dementia. Hum Psychopharmacol Clin Exp. 2006;21:1-12.
37. Kyomen HH, Hennen J, Gottlieb GL, et al. Estrogen therapy and noncognitive psychiatric signs and symptoms in elderly patients with dementia. Am J Psychiatry. 2002;159:1225-1227.
38. Rosenheck RA, Leslie DL, Sindelar JL, et al. Cost-benefit analysis of second-generation antipsychotics and placebo in a randomized trial of the treatment of psychosis and aggression in Alzheimer disease. Arch Gen Psychiatry. 2007;64:1259-1268.
39. Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355: 1525-1538.
40. Jeste DV, Blazer D, Casey D, et al. ACNP White Paper: Update on Use of Antipsychotic Drugs in Elderly Persons with Dementia. Neuropsychopharmacology. 2008;33:957-970.
41. US Food and Drug Administration Public Health Advisory. Deaths with antipsychotics in elderly patients with behavioral disturbances. http://www.fda.gov/cder/drug/advisory/antipsychotics.htm. Accessed May 27, 2008.
42. Howard RJ, Juszczak E, Ballard CG, et al. Donepezil for the treatment of agitation in Alzheimer’s disease. N Engl J Med. 2007;357:1382-1392.
43. American Psychiatric Association (APA). Practice Guideline for the Treatment of Patients With Alzheimer’s Disease and Other Dementias. Arlington, VA: American Psychiatric Association; 2007.


___
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. Dr Whitfield is a biostatistician in the department of psychiatry at Massachusetts General Hospital.