Advertisement

Agitation

  • Anne P. F. Wand
  • Brian DraperEmail author
Chapter

Abstract

Agitation, a term that includes behaviour such as excessive motor activity, verbal and physical aggression, is common in people with dementia. The assessment and management of agitation in older people can be challenging in primary care. Agitation may be the initial presentation of an early dementia, with a differential diagnosis that includes delirium, agitated depression, late life psychoses and anxiety disorders. In persons with established dementia, factors that contribute to agitation include acute medical problems, physical discomfort, communication difficulties, misinterpretations, carer and environmental problems and psychiatric comorbidity. Prevention of agitation by appropriate training of carers to provide person-centred care and by adapting the physical environment to meet the needs of people with dementia is paramount. Interventions to manage agitation should focus on non-pharmacological strategies first including addressing physical needs (e.g. pain relief), providing individualized psychosocial activities (e.g. physical exercise, music therapy, aromatherapy) in a regular structured program, educating and supporting the carers and optimizing the environment. In general, pharmacotherapy with psychotropic medication should be reserved for the more severe forms of agitation not responding to non-pharmacological interventions or when safety is seriously compromised and initially be used in trials of up to three months duration.

Keywords

Neuropsychiatric symptoms Behavioural and psychological symptoms of dementia 

References

  1. 1.
    Cummings J, et al. Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition. Int Psychogeriatr. 2015;27(1):7–17.CrossRefGoogle Scholar
  2. 2.
    Draper B, Finkel SI, Tune L. Module 1-an introduction to BPSD. In: Draper B, Brodaty H, Finkel SI, editors. The IPA complete guides to BPSD-specialists guide. 4th ed. Northfield: International Psychogeriatric Association; 2015. p. 1.1–1.16.Google Scholar
  3. 3.
    Steinberg M, et al. Point and 5-year prevalence of neuropsychiatric symptoms in dementia: the Cache County study. Int J Geriatr Psychiatry. 2008;23:170–7.CrossRefGoogle Scholar
  4. 4.
    Bergh S, Selbaek G. The prevalence and the course of neuropsychiatric symptoms in patients with dementia. Norsk Epidemiol. 2012;22(2):225–32.CrossRefGoogle Scholar
  5. 5.
    Steinberg M, et al. The persistence of neuropsychiatric symptoms in dementia: the Cache County Study. Int J Geriatr Psychiatry. 2004;19:19–26.CrossRefGoogle Scholar
  6. 6.
    Peters ME, et al. Prevalence of neuropsychiatric symptoms in CIND and its subtypes: The Cache County Study. Am J Geriatr Psychiatr. 2012;20(5):416–24.CrossRefGoogle Scholar
  7. 7.
    Stella F, et al. Neuropsychiatric symptoms in the prodromal stages of dementia. Curr Opin Psychiatry. 2014;27:230–5.CrossRefGoogle Scholar
  8. 8.
    Brodaty H, et al. Neuropsychiatric symptoms in older people with and without cognitive impairment. J Alzheimers Dis. 2012;31:411–20.CrossRefGoogle Scholar
  9. 9.
    Conn D. Module 8 - long-term care. In: Draper B, Brodaty H, Finkel SI, editors. The IPA complete guides to BPSD-specialists guide. 4th ed. Northfield: International Psychogeriatric Association; 2015. p. 8.1–8.33.Google Scholar
  10. 10.
    Wang H, et al. Module 7 - cross cultural and transnational considerations. In: Draper B, Brodaty H, Finkel SI, editors. The IPA Complete Guides to BPSD- Specialists Guide. 4th ed. Northfield: International Psychogeriatric Association; 2015. p. 7.1–7.51.Google Scholar
  11. 11.
    Ford AH. Neuropsychiatric aspects of dementia. Maturitas. 2014;79:209–15.CrossRefGoogle Scholar
  12. 12.
    Waggel SE, et al. Neuroticism scores increase with late life cognitive decline. Int J Geriatr Psychiatry. 2015;30(9):985–93.  https://doi.org/10.1002/gps.4251.CrossRefPubMedGoogle Scholar
  13. 13.
    Draper B, Wand APF. Behavioural and psychological symptoms of dementia. In: Pachana N, editor. Encyclopedia of geropsychology. in press.Google Scholar
  14. 14.
    Rendina N, et al. Substitute consent for nursing home residents prescribed psychotropic medication. Int J Geriatr Psychiatry. 2009;24:226–31.CrossRefGoogle Scholar
  15. 15.
    O’Connor D, Rabins P, Swanwick G. Module 5 - non-pharmacological treatments. In: Draper B, Brodaty H, Finkel SI, editors. The IPA complete guides to BPSD-specialists guide. 4th ed. Northfield: International Psychogeriatric Association; 2015. p. 5.1–5.13.Google Scholar
  16. 16.
    Meagher DJ, et al. Phenomenology of delirium. Assessment of 100 adult cases using standardized measures. Br J Psychiatry. 2007;190:135–41.CrossRefGoogle Scholar
  17. 17.
    Inouye SK, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–8.CrossRefGoogle Scholar
  18. 18.
    Bellilli G, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014;43:496–502.CrossRefGoogle Scholar
  19. 19.
    The Royal Australian College of General Practitioners. Medical care of older persons in residential aged care facilities. In: Silver book. 4th ed. East Melbourne: National Taskforce, The Royal Australian College of General Practitioners Victoria; 2006.Google Scholar
  20. 20.
    Yesavage JA, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982–1983;17:37–49.CrossRefGoogle Scholar
  21. 21.
    Alexopoulos GS, et al. Cornell scale for depression in dementia. Biol Psychiatry. 1988;23:271–84.CrossRefGoogle Scholar
  22. 22.
    Beck AT, Ward C, Mendelson M. Beck Depression Inventory (BDI). Arch Gen Psychiatry. 1961;4:561–71.CrossRefGoogle Scholar
  23. 23.
    Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. 2nd ed. Sydney: Psychology Foundation; 1995.Google Scholar
  24. 24.
    National Collaborating Centre for Mental Health. Depression. The NICE guideline on the treatment and management of depression in adults (updated edition) (National Clinical Practice Guideline 90). London: British Psychological Society and Royal College of Psychiatrists; 2010.Google Scholar
  25. 25.
    Jenkins C, McKay A. A collaborative approach to health promotion in early stage dementia. Nurs Stand. 2013;27:49–57.PubMedGoogle Scholar
  26. 26.
    Brodaty H, et al. Dementia: 14 essentials of assessment and care planning. Med. Today. 2013;14:18–27.Google Scholar
  27. 27.
    World Alzheimer’s Report 2009. London: Alzheimer’s Disease International; 2009.Google Scholar
  28. 28.
    Mrazek PJ, Haggerty RJ, editors. Reducing risks for mental disorders: frontiers for preventive intervention research. Washington, DC: National Academy Press; 1994.Google Scholar
  29. 29.
    Australian Institute of Health and Welfare. Dementia in Australia. Cat. no. AGE 70. Canberra: AIHW; 2012.Google Scholar
  30. 30.
    Lakey L, et al. Dementia 2012: a national challenge. London: Alzheimer’s Society; 2012.Google Scholar
  31. 31.
    World Health Organization and Alzheimer’s Disease International. Dementia: a public health priority. Chapter 6 Public understanding of dementia: from awareness to acceptance. http://www.who.int/mental_health/publications/dementia_report_2012. Accessed 4 Oct 2015.
  32. 32.
    Know the 10 signs. Chicago: Alzheimer’s Association. http://www.alz.org/alzheimers_disease_know_the_10_signs.asp. Accessed 4 Oct 2015.
  33. 33.
    Australian Institute of Health and Welfare. Dementia care in hospitals: costs and strategies. Cat. no. AGE 72. Canberra: AIHW; 2013.Google Scholar
  34. 34.
    Draper B, et al. The Hospital Dementia Services Project: Age differences in hospital stays for older people with and without dementia. Int Psychogeriatr. 2011;23:1649–58.CrossRefGoogle Scholar
  35. 35.
    Siddiqi N, House A, Holmes J. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35:350–64.CrossRefGoogle Scholar
  36. 36.
    Farrow M. Dementia risk reduction. A practical guide for health and lifestyle professionals. Alzheimer’s Australia; 2010.Google Scholar
  37. 37.
    Douglas S, James I, Ballard C. Non-pharmacological interventions in dementia. Adv Psychiatr Treat. 2004;10:171–9.CrossRefGoogle Scholar
  38. 38.
    Decision-making capacity and dementia. A guide for health care professionals in NSW. Mini-legal kit Series 1.7 ACCEPD (Capacity Australia). 2013.Google Scholar
  39. 39.
    Royal Australian and New Zealand College of Psychiatrists. Assessment and management of people with behavioural and psychological symptoms of dementia (BPSD): a handbook for NSW health clinicians. North Ryde: NSW Ministry of Health; 2013.Google Scholar
  40. 40.
    Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatr. 2006;14:191–210.CrossRefGoogle Scholar
  41. 41.
    Seitz D, Lawlor B. Module 6 - pharmacological management. In: Draper B, Brodaty H, Finkel SI, editors. The IPA complete guides to BPSD-specialists guide. Northfield: International Psychogeriatric Association; 2015. p. 6.1–6.35.Google Scholar
  42. 42.
    Jansen SL, et al. Melatonin for the treatment of dementia (review). Cochrane Database Syst Rev. 2011;3:CD003802.Google Scholar
  43. 43.
    Wand APF, et al. A multifaceted educational intervention to prevent delirium in older inpatients: a before and after study. Int J Nurs Stud. 2014;51:974–82.CrossRefGoogle Scholar
  44. 44.
    Livingston G, et al. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatr. 2005;162:1996–2021.CrossRefGoogle Scholar
  45. 45.
    Woods B, et al. Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database Syst Rev. 2012;2:CD005562.Google Scholar
  46. 46.
    Stanley MA, et al. The Peaceful Mind Program: a pilot test of a CBT-based intervention for anxious patients with dementia. J Geriatr Psychiatry. 2013;21:696–708.CrossRefGoogle Scholar
  47. 47.
    Fleming R, Crookes P, Sum S. A review of the empirical literature on the design of physical environments for people with dementia. Kensington: University of NSW; 2009. http://www.dementiaresearch.org.au/images/dcrc/output-files/147-summary_of_a_review_of_the_empirical_literature_on_the_design_on_physical_environments_for_people_with_dementia.pdf. Accessed 21 Jan 2015.
  48. 48.
    Brodaty H, et al. Dementia: 14 essentials of management. Med Today. 2013;14:29–41.Google Scholar
  49. 49.
    Burns K, Jayasinha R, Brodaty H. Managing behavioural and psychological symptoms of dementia (BPSD). A Clinician’s Field Guide to Good Practice. Sydney: Dementia Collaborative Research Centre, UNSW; 2014.Google Scholar
  50. 50.
    Kulmala J, et al. Association between frailty and dementia: a population-based study. Gerontology. 2014;60:16–21.CrossRefGoogle Scholar
  51. 51.
    National Institute for Health and Care Excellence. Dementia, disability and frailty in later life – mid-life approaches to prevention. NICE guidelines [NG16]. London: National Institute for Health and Care Excellence; 2015.Google Scholar
  52. 52.
    Morley JE. Frailty: diagnosis and management. J Nutr Health Aging. 2011;15:667–70.CrossRefGoogle Scholar
  53. 53.
    Chan DC, et al. A pilot randomised controlled trial to improve geriatric frailty. BMC Geriatr. 2012;12:58.CrossRefGoogle Scholar
  54. 54.
    Alzheimer’s Society. My name is not dementia. London: Alzheimer’s Society; 2010.Google Scholar
  55. 55.
    Higgins P. The spiritual and religious needs of people with dementia. Cathol Med Q. 2011;61:24–9.Google Scholar
  56. 56.
    Grossberg G, Luxemberg J, Tune L. Module 2 - clinical issues. In: Draper B, Brodaty H, Finkel SI, editors. The IPA complete guides to BPSD-specialists guide. 4th ed. Northfield: International Psychogeriatric Association; 2015. p. 2.1–2.29.Google Scholar
  57. 57.
    Cohen-Mansfield J, Marx MS, Rosenthal AS. A description of agitation in a nursing home. J Gerontol. 1989;44:M77–84.CrossRefGoogle Scholar
  58. 58.
    Reisberg B, et al. Behavioral symptoms in Alzheimer’s disease: phenomenology and treatment. J Clin Psychiatry. 1987;48(Suppl):9–15.PubMedGoogle Scholar
  59. 59.
    Cummings J, et al. The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology. 1994;44:2308–14.CrossRefGoogle Scholar
  60. 60.
    Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.CrossRefGoogle Scholar
  61. 61.
    Brodaty H, et al. The GPCOG: a new screening test for dementia designed for general practice. J Am Geriatr Soc. 2002;50:530–4.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.School of Psychiatry, University of New South WalesSydneyAustralia

Personalised recommendations