From the Guidelines
For managing agitation in hospitalized dementia patients, a multi-faceted approach prioritizing non-pharmacological interventions is strongly recommended. This approach is based on the American Psychiatric Association's practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia 1. The guideline emphasizes the importance of considering the goals and preferences of the patient and their surrogate decision maker, as well as balancing the potential benefits and harms of interventions.
Non-Pharmacological Interventions
Key non-pharmacological strategies include:
- Reorientation and maintaining a calm environment
- Ensuring adequate lighting
- Involving familiar caregivers
- Addressing unmet needs such as pain, hunger, and toileting
- Using distraction techniques
Pharmacological Management
If non-pharmacological interventions are insufficient, low-dose antipsychotics can be considered for severe agitation, but their use should be minimized due to the increased risk of mortality in elderly patients with dementia 1. Examples of low-dose antipsychotics include haloperidol, risperidone, or quetiapine, which should be used at the lowest effective dose for the shortest duration possible, ideally less than 1-2 weeks.
Special Considerations
- For patients with Lewy body dementia, antipsychotics should be avoided due to sensitivity risks.
- Alternative medications such as trazodone or lorazepam can be considered for acute situations.
- Regular reassessment is crucial to minimize medication use and to investigate the underlying cause of agitation, which often stems from delirium, pain, or environmental factors rather than dementia itself.
Personalized Approach
Hospital staff should document behaviors, triggers, and intervention effectiveness to develop personalized approaches for each patient, ensuring that the management strategy is tailored to the individual's needs and preferences. This approach is supported by the guideline's emphasis on considering the unique circumstances and clinical presentation of each patient 1.
From the Research
Management Strategies for Dementia Patients Experiencing Agitation
- Non-pharmacological interventions are being increasingly implemented to manage agitation in people with dementia, as medications often have adverse reactions and limited effectiveness 2
- Massage therapy, animal-assisted intervention, and personally tailored intervention are associated with more substantial reductions in agitation compared to other interventions and controls 2
- Music therapy is optimal for the management of agitation in institutionalized patients with moderately severe and severe Alzheimer's disease, particularly when the intervention includes individualized and interactive music 3
- Bright light therapy has little and possibly no clinically significant effects with respect to observational ratings of agitation, but decreases caregiver ratings of physical and verbal agitation 3
- Therapeutic touch is effective for reducing physical nonaggressive behaviors, but is not superior to simulated therapeutic touch or usual care for reducing physically aggressive and verbally agitated behaviors 3
Pharmacological Interventions
- Risperidone appears effective in controlling agitation in patients with dementia and has a relatively benign adverse-effect profile, but more clinical trials are needed to elucidate its role for this indication 4
- Citalopram, a selective serotonin reuptake inhibitor (SSRI), is associated with a reduction in the symptoms of agitation and a lower risk of adverse effects when compared to antipsychotics 5
- Atypical antipsychotics, such as quetiapine, olanzapine, and risperidone, are commonly used to treat agitation in dementia patients, but may have a higher risk of adverse effects compared to SSRIs 5
Prevention and Treatment Strategies
- Identifying and addressing precipitating factors, such as hospitalization, admission to nursing residencies, or changes in pharmacological regimens, can help prevent agitation in dementia patients 6
- Providing a calm and comfortable environment, and using non-pharmacological interventions, can help reduce agitation in dementia patients 6
- A comprehensive approach to managing agitation in dementia patients should include a combination of non-pharmacological and pharmacological interventions, as well as ongoing monitoring and evaluation 6