What Causes Agitation In Dementia Patients

Drugs Affecting Serotonergic Neurotransmission

Serotonin 5-HT2A Receptor Inverse Agonist: Pimavanserin

Among the various molecular targets considered as potential treatments of dementia-related psychosis or agitation/aggression, serotonin receptors have come into the limelight. Age-related decline in serotonin function has been linked with aggressive behavior in AD . Specifically, a reduced density and polymorphism of 5-HT2AR have been observed with the onset of aggression and psychosis in patients with dementia . Therefore, modulation of the activity of 5-HT2AR seems to be a promising therapeutic strategy for reducing psychiatric symptoms that matches closely with the disease pathology.

Structure and receptor profile of pimavanserin

Medical Workup: Rule Out Delirium

Delirium is a common cause of agitation in patients with dementia owing to their advanced age and underlying brain pathology. It is important to remember that signs and symptoms of delirium, which may manifest as acute changes in cognition and/or an acute onset or increase in agitated behaviors, may be the only indicators of an underlying systemic illness. Therefore, a high index of suspicion for delirium and underlying medical condition is necessary when assessing the patient with dementia who is agitated.

The fundamental features of delirium are fluctuating disturbances of attention and level of consciousness that usually develop over a short period of time. The etiology of delirium tends to be multifactorial. Common causes of delirium include systemic medical illnesses, electrolyte disturbances, and medication or substance intoxication or withdrawal.

General Guidelines For The Selection Of Pharmacological Interventions

The recommended strategy for effective yet safe and tolerable treatment is to add or change only one medication at a time, thereby making the source of improvement, deterioration, or emergence of side effects more easily apparent. Always start at recommended geriatric doses and titrate up slowly.

The management of the elderly patient with AD who is agitated and other dementing disorders requires a comprehensive biopsychosocial approach. Nonpharmacological interventions should always be instituted first. If the symptoms persist and are distressing to the patient or are potentially harmful, then careful deliberationâweighing risks and benefitsâshould be carried out before initiating pharmacological management, particularly with antipsychotics. It is also important to keep in mind that these behaviors often are episodic in nature and may change or even disappear over the course of the dementing illness regardless of interventions. In many cases, a combination of both nonpharmacological and pharmacological interventions is necessary in order to decrease symptoms, improve quality of life, and delay institutionalization.

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No Easy Solutions But Improvement Is Usually Possible

As many of you know, behavior problems are difficult in dementia in large part because there is usually no easy way to fix them.

Many probably too many older adults with Alzheimers and other dementias are being medicated for their behavior problems.

If your family is struggling with behavior problems, I know that reading this article will not quickly solve them.

But I hope this information will enable you to make more informed decisions. This way youll help ensure that any medications are used thoughtfully, in the lowest doses necessary, and in combination with non-drug dementia behavior management approaches.

To learn about non-drug management approaches, I recommend this article: 7 Steps to Managing Difficult Dementia Behaviors

And if you are looking for a memory care facility, try to find out how many of their residents are being medicated for behavior. For people with Alzheimers and other dementias, its best to be cared for by people who dont turn first to chemical restraints such as antipsychotics and benzodiazepines.

This article was first published in 2016, and was last updated by Dr. K in May 2022.

Coping With Agitation And Aggression

When taking care of a person who has agitation and dementia, it may be advisable to consult a doctor for a thorough medical check-up.

The professional will recommend treatment based on a careful diagnosis that helps them to determine possible causes. In some instances, the doctor may prescribe medication that will help reduce agitation.

Sadly, most medicines come with a wide range of side effects such as stroke, heart problems, risk of falls, or even death.

People can also try non-drug therapies to help manage agitation such as:

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Tips For Preventing Agitation

Some simple routine changes can help prevent agitation. Use the following person-centered care guidelines to help prevent agitation in dementia patients.

• Enable your loved one to feel in control. Even if theyre not able to perform tasks on their own, give them a chance to make small decisions, like what to wear, eat, or do next.
• Maintain a routine. An unpredictable routine may cause confusion and result in agitation. Consistency is key, so work together to set times for bathing, dressing, and eating. Try to adhere to the schedule, as best as possible.
• Build quiet times into the day. Continuously hopping from one activity to the next may be tiring and confusing for a person with dementia. Instead, try to take breaks in between to help them process thoughts and change.
• Place well-loved objects and photographs around the house. Such objects can offer a sense of security and comfort, and they also help your loved one to reminisce.
• Limit the number of people in a room. It can be overwhelming for someone with dementia to be around many people at once. Find a comfortable number of people they can socialize with and try not to exceed it.

To prevent agitation in dementia patients, its also important to take care of yourself. Your mood may also affect theirs. If you find yourself frustrated with your loved ones restlessness, take a step back to breathe and relax. This will allow you to revisit problems with a clear mind.

How Can I Treat Dementia

Providing the right kind of environment, treating a patient with medications, and getting support for the family are just some of the ways that professionals treat dementia and the agitation that goes along with it. For instance, some people may become agitated when they feel physically uncomfortable. Doctors will likely talk with the family about keeping the patient comfortable and providing a routine and support.

Medications can also help to lessen agitation. Sedation may be used in a crisis, and may make a patient drowsy for a few hours. There are long-term treatments that do not cause these effects, but it can sometimes take weeks before medication begins to work. An antipsychotic can reduce delirium and psychosis, and doctors sometimes prescribe benzodiazepines or trazodone to help with insomnia. They may prescribe antidepressants for depression or pain from arthritis when over-the-counter methods dont work. Buspirone can help with long-term anxiety control. To reduce anger and aggression, a doctor might suggest divalproex for long-term treatment. An antipsychotic can also be used in some cases. The doctor will need to make sure that the patient does not have any other health conditions or medications that will interact with these drugs before prescribing medications.

For more on the topic of Dementia, weve included the following expert consensus documents as reference materials:

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Special Considerations And Other Classes Of Medications

Patients may exhibit BPSD because they are experiencing pain, but no longer have the capacity to verbalize their discomfort. Data from RCTs support the use of analgesics to reduce BPSD. A recently published review noted three RCTs where acetaminophen, morphine, or long-acting oxycodone reduced symptoms of BPSD over 8-week time among nursing home residents . Additionally, investigators in a clustered site study in Norwegian nursing homes 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.

Various agents have been explored in case series and clinical trials to afford more options for clinicians and patients. Mania is common among patients with dementia experiencing aggression, and lithium may hold promise as a potential treatment for this manifestation of BPSD. As of August 2018, an ongoing clinical trial is investigating whether lithium is an effective treatment for aggression among older adults with moderate to severe AD . In a different study utilizing allopurinol, among eight veterans with dementia experiencing refractory aggression, six of the eight receiving allopurinol demonstrated reduced aggressive episodes .

Causes Of Agitation In Seniors With Alzheimers

< ![CDATA[Its heartbreaking to watch a senior loved one with Alzheimers disease lose their memory and struggle with daily activities. Tasks such as getting dressed or eating can become a challenge.

But when a loved one with Alzheimers becomes agitated, its especially difficult to deal with. If you dont have any medical or senior care training, you may be at a loss about what to do.

Understanding some of the main causes of Alzheimers-related agitation can help you minimize anxiety and angry outbursts by avoiding stressful situations.

And if you cant prevent a difficult behavior completely, at least you will be better prepared to manage it.

5 Reasons a Senior with Alzheimers Gets Agitated

1. Fear or fatigue

Older adults with Alzheimers live in a scary, unfamiliar world. The fatigue that comes from trying to understand their surroundings often causes agitation.

2. A break in routine

Its hard enough for someone with Alzheimers to understand their everyday world when things around them remain stable. A break in routineeven seemingly positive changes like a visit from friendscan cause agitation.

To prevent agitation in these situations, explain in advance to your loved one whats happening.

3. Perceived threats

People with Alzheimers often become agitated when they perceive a threat. And what we view as normal could be seen as a threat to someone with Alzheimers.

4. A change in caregivers

5. A change in location

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Ways To Respond To Agitated Behaviours

• Stay calm and speak in a reassuring voice.
• Distraction is a useful approach. Suggest having a cup of tea, going for a walk or looking at a magazine together.
• Use strategies that work for you. For example, if questions are being repeated, answering the questions may help. Others find that ignoring the questions works best. Consider the intention behind the questions. The person may need reassurance about something they are unable to express.

Managing Paranoia And Delusions

A number of strategies can help with managing paranoia and delusions. When interacting with someone who has these symptoms:

• Do not argue: Delusions are strong beliefs and are unlikely to change in response to logic or reasoning. Arguing may have the opposite effect, causing the person to become more convinced that people are against them.
• Try not to take offense: Delusions and accusations can be upsetting to watch, but it is important to remember that they come from changes in the brain. The person experiencing them does not know they are not real.
• Listen: Allow the person to express their feelings and ideas. Pay attention to the emotions they express, even if their facts are incorrect.
• Acknowledge: To show understanding, repeat what the person has said back to them. For example, I understand that you do not feel safe. That sounds frightening.
• Offer reassurance: If possible, give the person a simple explanation to show why their worries are unfounded. For example, if they are convinced that someone stole something, a caregiver might remind them that the item is in storage.
• Use distraction: Switching the persons attention to something else may prevent them from getting increasingly agitated. Try to distract the person with something they enjoy or change the setting by taking them for a walk or a drive.
• Avoid triggers: Avoid violent imagery on television, which may feel real to the person and make delusions worse.

Elder abuse can include:

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Preventing Agitation In Alzheimer’s Patients

Preventing agitation before it begins can be very helpful. Avoiding known triggers is a big step in reducing the likelihood of agitation. Stay away from places or situations that are known to be too much and simplify the daily routine. Try to find a way to get some physical activity every day, and work to create a calm home environment. Keeping tabs on the person’s basic needs like hunger, thirst, toileting, and fatigue can also go a long way in keeping their emotions and behavior stable.1

Alzheimer’s And Other Causes Of Dementia

There are several disease processes that can result in dementia. These causes include Alzheimer’s disease, Lewy-body disease, Parkinson’s Disease, Vascular dementia, and head injury to name a few. Alzheimer’s disease is the most common form of dementia, representing approximately 75% of all cases. Alzheimer’s disease is marked by a gradual functional decline, with difficulties with naming, rapid forgetting of newly learned information, and changes in executive functioning. Other forms of dementia have symptoms that overlap with those of Alzheimer’s disease, but the particular pattern of impairment differs for each disease. For example, patients with Lewy-body dementia usually demonstrate fluctuating levels of function and cognition, with relatively preserved naming, spared memory storage but impaired retrieval, and behavioral manifestations such as hallucinations early in the disease process.

The clinical symptoms of dementia fall into two categories: cognitive and neuropsychiatric. Cognitive symptoms include impairments in memory, language, orientation, recognition, and executive functions. In the case above, Mrs. R.’s forgetfulness and inability to use common household items he was previously proficient with are examples of cognitive deficits.

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Therapeutic Strategies For Hospitalized Patients

Unfortunately, the PCC approach is challenging in hospital settings, given the short length of the patient stay and the necessity of rapid interventions . However, the presence of pain and intercurrent pathologic conditions has been associated with the onset of aggressiveness, anxiety, and agitation and should be addressed. Furthermore, the direct assessment of unmet needs in hospitalized patients, which is often less recognized and identified than expected, can provide a more time-effective approach in a clinical environment, according to the standards of Needs-driven care based on the Unmet Needs Model . Nonetheless, cognitively impaired patients may experience difficulties communicating feelings of discomfort, pain, and loneliness, thereby making the assessment difficult . In nursing homes or at the patient home, the Needs-driven care is ancillary to the PCC and the most successful given the presence of familiarity and closed relationships with the patients.

How To Support A Person With Dementia Who Has Anxiety

Encourage them to:

• talk about their worries or fears
• If something very upsetting or traumatic has happened recently or in the past, the person may find it helpful to talk about their feelings however, if it was severe emotional trauma, ask a professional counsellor or psychotherapist for help first .
• If they are not comfortable discussing sensitive issues with someone they know, it may help if they instead talk to a professional counsellor or therapist.

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Prevalence Of Agitation/behavioral Symptoms In Ad

Fifty-five studies reported the prevalence of agitation and or behavioral symptoms in AD . Study types included cross-sectional , longitudinal or retrospective longitudinal , and before/after study/interrupted time series .

The overall prevalence of agitation ranged from 5% to 88% across all studies , with 21 showing a prevalence of agitation 50%. Twenty-three of the 55 studies reported prevalence of at least one neuropsychological symptom and reported a range of 40% to 100%. Community-dwelling or outpatient clinic participants were the primary population studied in 26 studies NH or group home residents were the primary population in 16 studies a combination of NH and community-dwelling participants were the primary population in five studies hospital patients were the primary population in five studies, and three studies did not report the source of their primary population. Most studies screened participants only for AD or dementia , while a couple screened for memory loss/cognitive impairment .

Table 3. Agitation studies reporting prevalence, natural progression, and association with AD severity

* One study U.S./Europe.

Abbreviations: AD = Alzheimers disease NPS = neuropsychiatric symptoms U.S. = United States.

Figure 2. Prevalence of agitation by geographic region. Abbreviation: U.S. = United States.

Aggression And Agitation In Dementia

Behavioral and psychological symptoms are very common in dementia, and affect up to 90% of people living with dementia. In addition to memory changes, people with dementia may experience agitation, psychosis, anxiety, depression, and apathy. These behavioral symptoms often lead to greater distress than memory changes.

When people with dementia become agitated or aggressive, doctors often prescribe medications to control their behaviors in spite of the known risks of serious side effects. The most frequently prescribed medication classes for agitation in dementia carry serious risks of falls, heart problems, stroke, and even death.

Caregivers, who often experience burnout in managing aggressive behaviors, welcome medications that can temporarily decrease agitation. Unfortunately, aggressive and agitated behavior often contributes to the decision to transition a loved one to an alternative living situation.

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What You Can Do About Medications And Difficult Dementia Behaviors

If your relative with dementia is not yet taking medications for behaviors, consider these tips:

• Start keeping a journal and learn to identify triggers of difficult behaviors. You will need to observe the person carefully. Your journaling will come in handy later if you start medications, as this will help you monitor for benefit and side-effects.

• Learn to redirect and de-escalate difficult dementia behaviors. Contact your local Alzheimers Association chapter or local Area Agency on Aging to find support near you. You can also learn a good approach in this article: 7 Steps to Managing Difficult Dementia Behaviors

• Ask your doctor to help assess for pain and/or constipation. Consider a trial of scheduled acetaminophen, and see if this helps.

• Consider the possibility of depression. Consider a trial of escitalopram or a related antidepressant, but realize any effect will take weeks to appear.

• For all medications for dementia behaviors:
• Monitor carefully for evidence of improvement and for signs of side-effects.
• Doses should be increased a little bit at a time.
• Especially for antipsychotics, the goal is to find the minimum necessary dose to keep behavior manageable.

If your relative with dementia is currently taking medications for behaviors, then you will have to consider at least the following two issues.

The other issue is to make sure you are aware of any risks or side-effects that the current medications may be causing.