Non-medication Management of Agitated Behavior in Dementia

PatientsJosepha A. Cheong, MD

University of Florida Departments of Psychiatry and Neurology

Chief, Division of Geriatric Psychiatry

1. Murphy SL. Natl Vital Stat Rep. 2000;48:1-106.

2. Evans DA. Milbank Q. 1990;68:267-289.

Current Prevalence of AD• AD is the fourth leading cause of death due to disease

for people > 65 years of age in the United States1

• Approximately 4 million people in the United States have AD2

• AD is a progressive, neurodegenerative disease involving:

– Loss of memory and other cognitive functions– Decline in ability to perform activities of daily living– Changes in personality and behavior– Increases in resource utilization– Eventual nursing home placement

AD Is the Most Prevalent Type of Irreversible Dementia

Guttman R et al. Arch Fam Med. 1999;8:347-353.McKeith IG et al. Neurology. 1996;47:1113-1124.

Cherrier MM et al. J Am Geriatr Soc. 1997;45:579-583.

VaD, vascular dementia;DLB, dementia with Lewy bodies;FTD, frontotemporal dementia.

, reflects difficulties diagnosing/reporting dementias; only estimations of prevalence can be made.

0

20

40

60

80

100

AD VaD DLB FTD Other

Irre

vers

ible

dem

enti

as (

%)

Disease Progression in Alzheimer’s Disease

0 1 2 3 4 5 6 7 8 9

Years from diagnosis

Cognitive ability

Functional ability

Behavioral problems

Caregiver time

0%

100%

Change indisease

progression

What is Agitated Behavior?

• Non-cognitive symptom of dementia (cognitive = memory loss, language difficulty)

• 2 types of non-cognitive symptoms:– Psychiatric– Behavioral

Psychiatric Symptoms

• Personality changes

• Depression

• Hallucinations

• Paranoia

• Misidentifications

• Mania» Alzheimer’s Disease International Factsheet

Behavioral Disturbances

• Aggression• Agitation• Wandering• Sexual disinhibition• Incontinence• Increased eating• Screaming

20-30%

>80%

25 - 50%

10%

50-60%

5-10%

5%

Modified – Alzheimer’s Disease International Factsheet

Why Manage These Symptoms?

• Caregiver stress and burden

• Stress on the patient

• Precipitant of nursing home placement

• Very manageable with non-medication and medication treatment

Why Non-medication Management?

• Less restrictive

• Effective in early dementia

• Fewer complications

• Stresses the importance of family and non-medical caregivers

General Principle

How would I deal with this problem behavior if this person

were a 3-5 year old child?

Assessment

• Rule out any environmental disturbance– change in home setting– change in the staff/family members– death of a pet

• R/o any possible medical illness– urinary tract infection– dehydration

Assessment

• R/o drug-drug interactions or drug intolerance

• When does the behavior occur– constant regardless of stimuli– specific time of day– with caregiving activity

Assessment

• Endocrine

• Iatrogenic - consider non-prescription medications

• Injury

• Intoxication

Treatment

• Behavioral Intervention– redirection– no-fail environment

• adjusting the environment to meet the needs and the limitations of the patient

– structure and consistency– avoid overstimulation

Specific Problems

Wandering

• >50% of AD pts wander

• 86% are located w/in 5 miles of home

• 37% are found w/in 1 mile of home

• 14% are found > 5 miles from home

2002 – Meredith Rowe – UF College of Nursing, Institute of Aging

Wandering

• Planned activities to counteract boredom

• Reassurances

• Redirection

• Red STOP sign

• Disguise the door

Wandering

Safety• Appropriate identification

• Bright vest

Wandering

Alzheimer’s Association Safe Return• Education• National photo/info database• 24 hour toll-free emergency crisis line

– 1-888-572-8566– 1-800-272-3900– www.alz.org

Baker Act - 52/32

• 52 - involuntary evaluation

• 32 - involuntary committment

Referral

Shands at UF

Inpatient Geriatric Psychiatry Unit

Intake Coordinator 352-265-5411

GO GATORS!