Grandma is Acting Out

CASE:  Your patient brings in her grandmother (82 yrs old diagnosis with dementia) with complaints that she is up all night screaming incoherently, strikes out at caregivers, and angers easily.

What can you offer your patient to better manage her mother’s agitation?

Dementia patients commonly have behavioral and psychological symptoms that present in several clusters that include psychosis (delusions, hallucinations) and agitation/aggression, and disinhibition (agitated behaviors) Agitation and psychotic symptoms in demented patients is common, occurring in up to 30% of patients and may increase with disease progression. Dementia patients with agitation and other neuropsychiatric disorders cause significant stress on the caregivers, lead to excess hospitalizations and nursing home admissions, and carry higher mortality.  Environmental and non-pharmacologic interventions are the mainstay of treatment. These include reducing ambient noise and clutter, establishing schedules of activities, periodic orientation. It is important to stay alert to possible sources of pain that the patient may be experiencing but unable to express, and manage these as appropriate. Of note 36% of patients with agitated dementia have an underlying undetected illness.

In evaluating patients with dementia presenting with agitation or other behavioral problems, consider the three main factors that contribute:

Patient-related: acute medical illness, underlying psychiatric illness, sensory deficits

Care-giver related: poor communication, emotional instability

Environmental factors: clutter, overstimulation, understimulation

Pharmacologic therapies should be reserved for severe conditions that are not well managed just by non pharmacologic therapies alone. Note that the FDA has NOT approved any medication for the management of behavioral conditions related to dementia so all of the medications discussed below are used in an off label manner.

Anti-psychotics. The atypical anti-psychotics, risperidone and aripiprazole, have been shown in 15 randomized controlled trials to be modestly effective at managing behavioral symptoms. Oddly, presence of psychosis was associated with less clinical effectiveness for agitation than in patients without psychosis. The atypical anti-psychotics are not without their adverse effects. Based on re-analysis of 17 RCTs in 2005, the FDA issued a black box warning that indicated a 1.7 fold increase in mortality risk in patients treated with these drugs. Beyond excess mortality, this class of drugs was also associated with extrapyramidal effects, hyperprolactinemia, prolonged QT syndrome (thought to be the source of excess mortality) and greater anti-cholinergic side effects. Conventional antipsychotics such as haloperidol also carry a similar black box warning.

Benzodiazepines.  Curiously, there are no RCTs on clinical effectiveness of this class of drug in the management of agitated dementia, and are NOT recommended in the management of behavioral issues in dementia with the exception of acute crisis. Of particular concern with the use of benzodiazepines is the increased risk of dependency and worsening of dementia as well as excess falls.

Take home lessons are:

  1. evaluate the three categories of factors and address each
  2. Preference is for non pharmacologic strategies (environment, caregiver)
  3. use atypical anti-psychotics if behavior is severe and not managed well by non pharmacologic interventions
  4. Be cautious. Avoid benzodiazepines.