Treatment of Agitation in the Elderly Current Concepts

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Treatment of Agitation in the ElderlyCurrent
Concepts

• Here Comes the Sun (down)
• Steve Anisman, MD

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Whats Got You All Riled Up?
The fatal mistake Assume its dementia.
Delirium (Thanks, Dr. Studley)   Psychiatric
disorders Psychosis - delusions and hallucinatio
ns Depression Bipolar Personality Disorders
Anxiety Sleep Disorders  
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Whats Got You All Riled Up?
The fatal mistake Assume its dementia.
Or, maybe it is. But what kind of dementia?
Alzheimers Progressive, consistent, loss of rec
ent memory, personality change
Vascular (multi-infarct) Can be similar, but oft
en with focal neuro findings, and with infarcts
on imaging Lewy-Body   Parkinsonian features, wa
xing waning Sx, visual hallucinations,
hypersensitivity to typical antipsychotics
will get EPS
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Whats Got You All Riled Up?
The fatal mistake Assume its dementia.
Or, maybe its not even pathology.
Mistreatment Bad day Cranky from long hospitaliz
ation Upset with diagnosis Something happening a
t home or at work Room is too hot, roommate is an
noying, too much noise in hall Etc Etc
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Whats Got You All Riled Up?
Unfortunately, most of the research on aggression
in the elderly focuses on dementia.
Best estimates suggest that 67.5 of community d
welling people with Alzheimers qualify as
excessively disturbed, when tested using the
Cohen-Mansfield Agitation Inventory (CMAI).
(Tractenberg 2002)
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How Can We Rile You Down?
Define target symptoms
D E M E N T I A
Environmental factors addressed (noise,
roommates, etc)
Medical illness reviewed (pain, thyroid,
infections, B12, folate, etc)
Educate caregivers
Neuropsychiatric diagnoses established
(depression, anxiety, etc)
Targeted pharmacotherapy
Intervene with behavioral management
Avoid pharmacologic toxicity
(Gearhart 2001)
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Non-Pharmacologic Interventions
Sensory Social Contact Behavior Therapy Staff T
raining Structured Activities Environmental Inte
rventions Medical/Nursing Interventions Combinat
ion Therapies
These all show benefit, but not always
significant.
(Cohen-Mansfield 2001)
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Pharmacologic Interventions
Daily psychotropics are used in 59 of nursing
home residents, typically on a long-term basis.
31 antidepressants (70 are SSRIs)
More likely if in an institution with more
physician contact
23 use neuroleptics Typically used for behavior
al and psych symptoms
22 use benzos Typically used for sleeping disor
ders
There is enormous variability between providers
antidepressant use ranges from 10-63,
neuroleptic use ranges from 0-61. (Ruths 2001)
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Pharmacologic Interventions
The Fundamental Rules of

• Dont assume dementia
• Try to treat a more specific symptom than
  agitation
  
• Start low, go slow (but go!)
• Avoid toxicity
• Use lowest effective dose
• Withdraw after an appropriate period and observe
  for relapse
  
• Serial trials are sometimes needed
• The role of combinations is unclear

(Adapted from Tariot 2000)
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Antidepressants
Citalopram (Celexa SSRI) was shown to benefit
patients who were agitated but did not meet
criteria for depression. (Pollock 2002)
Fluoxetine (Prozac) and Sertraline (Zoloft) are
considered most effective. (Verma 2002)
Paroxetine (Paxil) and Venlafaxine (Effexor) are
associated with discontinuation syndromes if
stopped suddenly (Verma 2002)
Avoid tertiary tricyclics (amitriptyline,
imipramine, doxepin) as their anticholinergic
properties can cause delirium and impair
cognition (Verma 2002)
Electroconvulsive therapy (ECT) is safe and
effective in treating geriatric depression
(Benbow 1989)
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Antidepressants
(Modified from Tariot 2001)
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Neuroleptics
Olanzapine (Zyprexa an atypical antipsychotic)
is better than benzos in treating anxiety.
(Meehan 2002, Mintzer 2001) Good choice for
behavioral and psychotic Sx. (Street 2001) Also
an excellent choice for patients with mood
lability and mania. (Brennan)
Risperidone (Risperdal another atypical) and
Olanzapine went head to head in male geriatric
inpatients and had equal efficacy, but
Risperidone is 1/3 the cost. (Verma 2001)
Risperidone at low doses (0.5 to 1.5 mg/day)
decreases delusions, hallucinations,
agitation/aggression/irritability, and continues
to have benefit over time, with preservation of
cognitive function. (Rainer 2001)
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Neuroleptics
Switching patients abruptly from Haldol to
Risperidone has no ill effects. (Lane 2002)
Although vascular dementia is more associated
with depression, and Alzheimers with delusions,
both types respond equally well to Risperidone.
(Lawlor 2001)
If youve got Lewy-body dementia, avoid typicals.
In fact, your best choice is Exelon
(rivastigmine, a cholinesterase inhibitor) it
improves cognition, independence, mobility,
ADLs, and sleep disruption. Aricept (donepezil),
even though its in the same class, is less
effective and can cause extrapyramidal symptoms.
(Maclean 2001)
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Neuroleptics
If youre depressed and demented, Trazodone
(Desyrel, SSRI) may be your best choice. If
youre also delusional, adding Haldol wont help
you. (Sultzer 2001) In fact, if youre agitated,
Haldol may not help you at all it improves
aggression, but not agitation. (Lonergan 2001)
The decision to prescribe antipsychotic
medication for agitation in dementia should
involve a careful analysis of the risks as well
as the potential benefits. Elderly people with
dementia are particularly sensitive to the common
adverse effects of these drugs, such as sedation,
parkinsonism, tardive dyskinesia, postural
hypotension, and falls. In addition, some
evidence suggests that these agents may be
associated with accelerated cognitive decline
(McShane et al 1997) (Howard 2001)
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Neuroleptics
(Modified from Tariot 2001)
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Mood Stabilizers
Carbamazepime (Carbatrol, Tegretol) shows modest
benefits for Pt who have not responded to
antipsychotics - particular improvement in
hostility, but worsening in hallucination. (Olin
2001)
Gabapentin (Neurontin) was useful in one Pt with
vascular dementia who did not respond to
antidepressants, benzos, and neuroleptics - Pt
reduced agitation, lability, and sexual
inappropriateness. Drug has favorable adverse
effect profile in elderly. (Miller 2001)
Lithium and valproate may have neuroprotective
properties (no evidence for same benefit from
other mood stabilizers). (Manji 2000)
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Mood Stabilizers
(Modified from Tariot 2001)
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Anxiolytics
Neuroleptics are much more effective than
anxiolytics for long-term use. If you need to use
a benzo for something brief, such as a procedure,
choose a short-acting rather than a long-acting
medication (Tariot 2001)
Short Acting----------------------------------Long
Acting
Alprazolam (Xanax) Estazolam
(Prosom) Chlordiazepoxide (Librium)
Midazolam (Versed) Lorazepam
(Ativan) Clonazepam (Klonopin)
Oxazepam (Serax) Temazepam
(Restoril) Clorazepate (Tranxene)
Triazolam (Halcion) Diazepam (Valium)
Flurazepam (Dlamane)
(Adapted from ePocrates)
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Anxiolytics
(Modified from Tariot 2001)
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Cholinesterase Inhibitors
Known long-term benefit, some evidence of
positive psychotropic effects as well. (Cummings
2000)
Particularly useful in Lewy body dementia and
Parkinsonian dementia. Other uses are less well
researched. (Verma 2002)
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Cholinesterase Inhibitors
(Modified from Tariot 2001)
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Other Medications
Beta blockers have high potential for
debilitating side effects (bradycardia,
hypotension, worsening of congestive heart
failure or asthma) in this age group, but small
studies indicate small improvement in aggression
in demented patients receiving 30-80mg
propranolol. (Shankle 95)
Anecdotes exist of benefit from estrogenic or
anti-andronergic drugs, but the evidence is weak
and often contradictory. Tagamet has recently
been discussed, and the benefit may stem from an
anti-andronergic effect. (Brennan)
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Pain Control
Untreated chronic pain may lead to decreased
physical functioning, increased falls, impaired
sleep and fatigue, anxiety, and depression. These
consequences are serious in the elderly patient
who may have marginal functional reserve.
Presenting Sx include withdrawal, change in MS,
yelling out, aggression, withdrawal, or refusal
to eat or ambulate. (Cutson, 2001)
In one study, scheduled acetominophen allowed
discontinuance of psychotropic medication in five
of eight nursing-home residents with agitated or
difficult behavior. (Douzigian 98)
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Pain Control

• Pain ladder with 3 steps (World Health
  Organization 1990)
  
• For persisting or increasing pain, start with
  non-opioid /- adjuvant
  
• If continues to persist or increase, add opioid
  while continuing non-opioid /- adjuvant
  
• For intractable pain or terminal dz, opioid /-
  non-opioid /- adjuvant

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Pain Control Step I
Elders should start at 50-66 of these doses.
Watch for GI bleed, dizziness, confusion, Na
water retention, exacerbation of HTN, hyperK,
renal toxicity follow lytes and renal labs 2
weeks after starting Rx, consider periodic occult
blood testing. If long-term use, consider adding
H2 blocker or PPI. (adapted from Abrahms 2000)
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Pain Control Step II
Codeine acetominophen Hydrodocodone
combined with aspirin
Oxycodone an NSAID For moderate pain, you ca
n choose 1 from column A and 1 from column B, or
use tramadol. Codeine use may be problematic. Dos
es greater than 1.5 mg/kg are not well tolerated,
and codeine requires activation by hepatic
enzymes that are not present in some patients and
that can be inactivated by inhibitors such as
cimetidine, quinidine, or fluoxetine.
Tramadol is a nonopioid that binds mu opiate
receptors. At recommended doses (400 mg/d), it is
safe and as well tolerated as acetaminophen or
aspirin plus codeine. Slow titration (i.e., 50-mg
increases every 3 days) minimizes development of
nausea, vomiting, dizziness, and vertigo. At
higher doses or in patients receiving monoamine
oxidase inhibitors, seizures have been noted.
Patients older than 75 years old with normal
renal and hepatic function should not receive
more than 300 mg/d. Patients of any age with
creatinine clearance less than 30 mL/min should
be dosed every 12 hours with a total dose not
exceeding 200 mg/d.
(Adapted from Abrahms 2000)
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Pain Control Step III
Elders should start at 25-50 of these doses.
Opioids are associated with constipation (should
typically give laxative concurrently, but watch
out for fiber which can exacerbate constipation
if poor PO) sedation urinary retention and
nausea/vomiting all typically diminish after
first few days nightmares and myoclonus
typically resolve with change to different agent
delirium more common with impaired cognition,
dehydration, poor renal function, polypharmacy .
(adapted from Abrahms 2000)
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Pain Control Adjuvants
(adapted from Abrahms 2000)
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Restraints
The Rules At Baystate, if the goal is to protect
lines necessary for the patients health
maintenance, nurses can use restraints without MD
orders.
MD-ordered restraints need to be renewed every 24
hours. Restraints for purposes other than line
protection cannot be used for more than 8 hours
without a signed (active) MD order. Restraints
should only be used for protection of essential
lines (not foley, KVO angio) or assaultive
behavior.
(Much of the information on this topic has been
modified from Corrigan 1998)
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Restraints
Nursing homes that used fewer physical restraints
had fewer falls and injuries than controls, even
when adjusted for cognition, ambulatory status,
psychotropic drugs. (Capezuti 1998)
Use of restraints actually increased agitation in
both nursing home and hospital patients (Verma
2002)
Archives of Internal Medicine concluded in 1992
that Restraints are overused in medicine
Despite their extensive use, there is virtually
no evidence to support the efficacy of
restraints The proper approach to the patient at
risk of falling is to address the contributing
factors that place the patient at risk, and,
where possible, correct them. (Marks 1992)
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Restraints
Use the least restrictive type of restraint
possible.
Mittens cover hands, allow arm movement but
patients lose the opposable thumb advantage vs
lower forms of life, such as lines, itchy parts.
Elbow Restraint (Freedom Sleeves) prevent
elbow flexion, make it difficult to reach much
above the waist, including lines and itchy parts.
Soft Restraints prevent movement of restrained
body part.
Hard Restraints prevent movement of restrained
body parts reserved for aggressive, violent (or
potentially violent) patients when soft
restraints have failed.
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Restraints
Posey (belt) used to keep patient in a chair or
bed, but allows freedom of movement of all
extremities.
Vest Restraint also used to keep patients in
chair, removes freedom of torso movement that was
preserved with the Posey.
Dont forget the constant companion possibly
the best protection against self-harm that
patients can have, and the least physically
restrictive. You lose the risks of restraints
(such as agitation, anger, asphyxiation, injury,
liability) while accomplishing many of the same
goals, plus you provide a pal.
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Take Home Points
Target meds (if meds are needed at all)
Avoid benzos (particularly long-acting)
SSRIs are a great place to start
Atypical neuroleptics are better than typicals,
but all neuroleptics should be used with caution
Treat Pain
Restraints often make things worse be careful
in using them
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Thank you
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References
Abrahm JL Pain assessment and management. Prim
Care 2001 Jun 28(2) 269-97 Benbow SM. The role
of electroconvulsive therapy in the treatment of
depressive illness in old age. Br J Psychiatry
1989 155 147-52. Capezuti E. The relationship b
etween physical restraint removal and falls and
injuries among nursing home residents. Journal of
Gerontology Medical Sciences 1998 53AM47-M52.
Cohen-Mansfield J, Werner P. Longitudinal changes
in behavioral problems in old age a study in an
adult day care population. J Gerontol A Biol Sci
Med Sci 1998 Jan 53(1) M65-71
Cohen-Mansfield J, Werner P. Longitudinal
predictors of non-aggressive agitated behaviors
in the elderly. Int J Geriatr Psychiatry 1999
Oct 14(10)831-34 Corrigan B, et al. Baystate Cl
inical Operations Manual 1998 CO 9.805
Cummings JL Cholinesterase inhibitors A new
class of psychotropic compounds. Am J Psychiatry
2000 Jan 157(1) 4-15 Cutson,T Long-term care i
n geriatrics management of pain in the older
adult. Clinics in Family Practice 3(3) 667-81,
2001 Douzjian M, Wilson C, Shultz M, et al A pr
ogram to use pain control medications to reduce
psychotropic drug use in residents with difficult
behavior. Annals of Long Term Care 6174-179,
1998 Gearhart M. Pharmacologic management of agit
ation in the older adult with dementia. Clin
Nurse Spec 2001 July 15(4) 158-9
Howard et al. Guidelines for the management of
agitation in dementia. Int J Geriatr Psychiatry
2001 16 714-7 Lane HY et al. Shifting from halo
peridol to risperidone for behavioral
disturbances in dementia safety, response
predictors, and mood effects. J Clin
Psychopharmacol 2002 Feb 22(1) 4-10
Lawlor B, Bhriain SN. Psychosis and behavioural
symptoms of dementia defining the role of
neuroleptic interventions. Int J Geriatr
Psychiatry 2001 16 S2-6. Lonergan E, Luxenberg
J, Colford J. Haloperidol for agitation in
dementia. Cochrane Database Syst Rev.
2001(4)CD002852 Maclean LE, Collins CC, Byrne EJ
. Dementia in Lewy bodies treated with
rivastigmine effects on cognition,
neuropsychiatric symptoms, and sleep. Int
Psychogeriatr 2001 Sep 13(3) 277-88.
Manji HK, Moore GJ, Chen G Lithium up-regulates
the cytoprotective protein Bcl-2 in the CNS in
vivo A role for neurotrophic and neuroprotective
effects in manic depressive illness. J Clin
Psychiatry 61(suppl 9)82-96, 2000
Marks W. Physical restraints in the practice of
medicine. Arch Int Med 152 2203-6, 1992 
37
References
Martin-Cook K et al. Impact of family visits on
agitation in residents with dementia. Am J
Alzheimers Dis Other Demen 2001 May-Jun 16(3)
163-6. Meehan T, Robertson S, Vermeer C. The impa
ct of relocation on elderly patients with mental
illness. Ast NZ J Men Health Nurs 2001 Dec
10(4) 236-42 Meehan, KM et al. Comparison of rap
idly acting intramuscular olanzapine, lorazepam,
and placebo a double-blind, randomized study in
acutely agitated patients with dementia.
Neuropsychopharmacology 2001 Apr 26(4) 494-504
Miller LJ. Gabapentin for treatment of behavioral
and psychological symptoms of dementia. Ann
Pharmacother 2001 Apr 35(4) 427-31.
Mintzer J et al. Olanzapine in the treatment of
anxiety symptoms die to Alzheimers disease a
post hoc analysis. Int J Geriatr Psychiatry 2001
Dec 16 Suppl 1 S71-7. Olin JT et al. A pilot ra
ndomized trial of carbamazepine for behavioral
symptoms in treatment-resistant outpatients with
Alzheimer disease. Am J Geriatr Psychiatry 2001
Fall 9(4) 400-5 Pollock BG et al. Comparison of
citalopram, perphenazine, and placebo for the
acute treatmet of psychosis and behavioral
disturbances in hospitalized, demented patients.
Am J Psychiatry 2002 Mar 159(3) 460-5
Rainer MK et al. Effect of risperidone on
behavioral and psychological symptoms and
cognitive function in dementia. J Clin Psychiatry
2001 Nov 62(11) 894-900 Ruths S, Straand J, Nyg
aard HA. Psychotropic drug use in nursing
homesdiagnostic indications and variations
between institutions. Eur J Clin Pharmacol 2001
Sep 57(6-7) 532-8 Shankle WR, Nielson KA, Cotma
n CW Low-dose propranolol reduces aggression and
agitation resembling that associated with
orbitofrontal dysfunction in elderly demented
patients. Alzheimer Dis Assoc Disord 1995 9
233-237 Street JS et al Long-term efficacy of ola
nzapine in the control of psychotic and
behavioral symptoms in nursing home patients with
Alzheimers dementia. Int J Geriatr Psychiatry
2001 Dec 16 Suppl 1 S62-70 Sultzer D et al. Doe
s behavioral improvement with haloperidol or
trazodone treatment depend on psychosis or mood
symptoms in patients with dementia? J Am Geriatr
Soc 2001 Oct 49(10) 1294-300
Tariot PN, et al Pharmacologic therapy for
behavioral symptoms of Alzheimer's disease. Clin
Geriatr Med 2001 May 17(2) 359-76
Tractenberg RE, Weiner MF, Thal LJ. Estimating
the prevalence of agitation in community-dwelling
persons with Alzheimers disease. J
Neuropsychiatry Clin Neurosci 2001 Winter 14(1)
11-8 Verma S. Behavioral disturbances in dementia
Nonpharmacological and pharmacological
management. Lecture Notes, May 18 2002.