From the Guidelines
For managing agitation in hospitalized dementia patients, a non-pharmacological approach should be prioritized, focusing on providing a predictable routine, simplifying tasks, and ensuring a safe environment, as recommended by the American Family Physician guidelines 1. When considering the management of agitation in dementia patients in a hospital setting, it's crucial to prioritize interventions that minimize morbidity, mortality, and improve quality of life.
Key Interventions
- Provide the patient with a predictable routine, including exercise, meals, and bedtime, to reduce confusion and agitation.
- Allow the patient to dress in their own clothing and keep possessions to maintain a sense of identity and comfort.
- Explain all procedures and activities in simple language before performing them to reduce anxiety and fear.
- Simplify tasks and break complex tasks into steps to avoid overwhelming the patient.
- Ensure that comorbid conditions are optimally treated to prevent exacerbation of agitation.
- Create a safe environment by removing hazards, installing safety locks, and using grab bars to prevent falls and injuries.
Pharmacological Interventions
While non-pharmacological interventions should be the primary approach, pharmacological interventions may be necessary in some cases.
- The American Psychiatric Association practice guideline 1 suggests that antipsychotic medications can be used to treat agitation or psychosis in patients with dementia, but their use should be judicious and carefully monitored due to the risk of adverse effects, including mortality.
- When medications are necessary, low-dose antipsychotics like haloperidol or quetiapine can be considered, but their use should be limited to the shortest duration possible, typically reassessing after 24-48 hours.
Monitoring and Safety
- All interventions, whether non-pharmacological or pharmacological, should be accompanied by close monitoring for adverse effects, including sedation, falls, and cardiovascular complications.
- The goal is to maintain patient dignity and safety while minimizing chemical restraint and addressing the underlying causes of agitation, such as pain, infection, or medication side effects.
From the Research
Dementia Patients with Agitation in the Hospital Setting
- Agitation is a common neuropsychiatric symptom in dementia patients, with a prevalence of 30-50% in Alzheimer's disease, 30% in dementia with Lewy bodies, 40% in frontotemporal dementia, and 40% in vascular dementia 2.
- The pathophysiological mechanism underlying agitation is represented by a frontal lobe dysfunction, mostly involving the anterior cingulate cortex (ACC) and the orbitofrontal cortex (OFC) 2.
- Agitation can be precipitated by several factors, including hospitalization, admission to nursing residencies, or changes in pharmacological regimens 2.
Treatment Options
- Acetylcholinesterase inhibitors and memantine can be initiated to enhance cognition, and if present, management of insomnia or sundowning with trazodone is indicated 3.
- Treatment with citalopram can be initiated with attention paid to potential prolongation of the QT interval 3, 4.
- Low doses of atypical antipsychotics such as risperidone or quetiapine can be effective after appropriate consideration of and disclosure of potential adverse effects 3.
- Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), can be used to treat agitation in dementia patients, with some studies showing a reduction in symptoms of agitation compared to placebo 5.
Safety and Efficacy
- The use of haloperidol for agitation in dementia is not supported by evidence, with no significant improvement in agitation and increased side effects 6.
- SSRIs, such as citalopram, appear to be tolerated reasonably well when compared to placebo, typical antipsychotics, and atypical antipsychotics 5.
- Future studies involving more subjects are required to determine if SSRIs, trazodone, or other antidepressants are safe and effective treatments for agitation and psychosis in dementia 5.