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.

What to Know but Not Forget About Dementia

CASE: One of your patients brings in her mother who she reports is having increasing forgetfulness. She is 82 years old, with longstanding hypertension and heart disease. No history of stroke. The forgetfulness was starting to be noticed in her late 60’s and has progressed gradually since then.

Does this patient have dementia? The Alzheimer’s Association recommends looking for the ten warning signs of dementia that include:

  • Memory loss that affects daily living or work
  • Difficulty performing familiar tasks
  • Problems with language
  • Disorientation in time and space
  • Poor or decreased judgement
  • Problems with abstract thinking
  • Misplacing things
  • Changes in mood or behavior
  • Changes in personality
  • Loss of initiative

Dementia is very common, affecting up to 50% in patients over 85 years of age, and 10% in patients 65 years. As we all age, our memories decline. However, primary care physicians should be alert to patients who are experiencing memory loss without other signs of cognitive impairment.  This is defined as mild cognitive impairment (MCI). Unfortunately up to 81% of patients who meet the criteria for dementia never receive a documented diagnosis. Up to 25% of patients with MCI progress to full dementia each year, and should be evaluated and managed.

Key diagnostic studies include a CBC, serum glucose, serum electrolytes with BUN and creatinine, serum B12 levels, liver function tests, thyroid screening with TSH and depression screening. The latter is crucial as many patients with depression present with mild cognitive impairment. At the present time, there is little evidence to screen for syphilis (unless specific risk factors exist), doing EEGs, APOE genotyping, MR or CT scans or SPECT scanning. Use of PET scans or genetic screening for Tau mutations are controversial.

If cognitive impairment exists, consider use of cholinesterase inhibitors or vitamin E in patients with mild to moderate dementia. Diagnose and treat depression and psychosis as appropriate. Many patients with dementia develop functional or behavioral problems. Consider the following:

  • Behavioral modifications (scheduled toileting)
  • Music especially during meals and bathing
  • Walking or light exercise
  • Pet therapy (yes with animals, not electrons)
  • Cognitive exercise