BetterConduct

In 2008, the Journal of Clinical Psychiatry published an algorithm for treatment of dementia-related agitation or aggression (Salzman et al, 2008).  This flow chart provides the skeletal framework for deciphering what issues are contributing to behavioral symptoms and suggests a sequence of management techniques. 

 

According to the algorithm, the first step is to discuss the behavioral issues and what pharmacological and non-pharmacological interventions have been attempted.  At this point, the algorithm indicates a discussion of possible future behavioral issues that could ensue.  (If you’re questioning this as we’re reading, see the chapter on the Japan study of BPSD and patterns in dementia under the Behavior tab.)

 

Next, an assessment of the individual’s skills and ‘level of alertness’ should be obtained and documented.  Past and present interests, hobbies, preferred activities, time of day ADLs are preferred (for example, some clients prefer to bathe in the morning while others prefer before bed), social activities, etc.  should be determined and a schedule developed.  This interview should be done with family members in addition to the client.  Also included would be strategies that provide comfort to the client—holding hands, back rub, lap blanket, preferred music, etc. 

 

At this point in the flowchart, if a “severe, persistent or recurrent agitated or aggressive behavior problem occurs” this warrants history of the behavior, environment, antecedents, etc. to be obtained from as many staff/family members as possible.  Patterns are investigated. 

 

The next step would be to review medications and their side effects as well as interactions with other medications.  Over the counter medication and supplements should also be included in this list.

Evaluate for pain, existing medical conditions (such as UTI), loneliness, fear, changes in routine and environment.  Does the person have a new roommate? Are there caregiver/staff changes? Are they over- or under-stimulated?   Does the client have a fever? Bedsores?  Is he/she constipated, hungry, or tired? (See chapter on PHALT).   Here is where the algorithm states “Optimize management with cognitive enhancers and antidepressant medications, as appropriate”.  I would argue that non-pharmacological interventions should be tried first as there are still no FDA approved medications for managing agitation and aggression in dementia clients more than 10 years after this algorithm was published.  Some medications can cause the very behaviors you are trying to address: for example, bladder control medications can cause agitation; sleep aids can cause tremors and hallucinations.

 

Environmental changes can be extensive. Covering mirrors, allowing for privacy, making sure the client is warm and comfortable, decreasing noise and clutter, decreasing/increasing stimulation, time outside in natural light, should all be attempted to see if the behavioral problem is eliminated or decreased in frequency or intensity. 

Another strategy would be to keep routines and required tasks as simple as possible.   Provide reassurance and a calm demeanor.  Point out successes, not failures.  Provide interaction that is not based on performance or response.  Physical exercise as simple as clutching a stress ball or as complex as walking may reduce aches and pains, take the focus off frustrations, and boost mood.  

 

Although studies may not show a benefit to all cases, alternative strategies can be used such as caring for a pet, aromatherapy, or occupational therapy.  Music, however, has been shown in several studies to decrease agitation and improve mood (Ijaopo, 2017).

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I would like to add a few points to this flowchart.  For behaviors that do not cause harm to the patient or caregiver and are not aggressive to the caregiver, one solution is to ignore or tolerate the behavior.  Comfort and reassurance should be provided.  Respond to the emotions behind the behaviors without trying to enforce our perception of reality on the client.  Their behavior is an attempt to communicate their needs and wants.  We owe it to them to try the least restrictive and least invasive strategies we can to alleviate the source of their discontent. 

 

Sources:

Ijaopo EO. Dementia-related agitation: a review of non-pharmacological interventions and analysis of risks and benefits of pharmacotherapy. Transl Psychiatry. 2017;7(10): e1250. Published 2017 Oct 31. doi:10.1038/tp.2017.199

 

Salzman C, Jeste DV, Meyer RE, et al. Elderly patients with dementia-related symptoms of severe agitation and aggression: consensus statement on treatment options, clinical trials methodology, and policy. J Clin Psychiatry. 2008;69(6):889–898. doi:10.4088/jcp.v69n0602.