Acute Management of Behavior Changes in Hospitalized Patients with Dementia

Acute Management of Behavior Changes in Hospitalized Patients with Dementia - #63

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Identify the specific difficult behavior and apply best practice management strategies.

Hospitalized patients with dementia who develop agitation or aggression.

Etiologies to Consider:

  • Determine if the behavior is actually due to delirium (consider the Confusion Assessment Methodology Score --CAM score).

  • Define any underlying precipitating factors/antecedent situation.

  • Review medications (medication withdrawal, new or recently stopped medications).

  • Rule out infection.

  • Rule out intoxication (drug, alcohol, other substances).

  • Assess for pain (if present, identify the source).

  • Assess for urinary retention/fecal impaction/skin irritation.

  • Define baseline cognition.

  • Assess/define sensory impairment.

  • Assess (change in) environment, especially overstimulation.

  • Define pre-existing psychiatric comorbidities.

  • Assess for patient frustration with being unable to complete a task that they are asked to perform (i.e. apraxia).

  • Identify any unmet needs (hunger, thirst, incontinence).

  • Identify and define agitation in hospitalized patients with dementia.
  • Describe non-pharmacologic and pharmacologic strategies for managing agitation.
  1. Pharmacotherapy of Dementia Behaviors Algorithm.Pharmacist’s Letter. October 2011.

  2. Schneider L, et al. Effectiveness of Atypical Antipsychotic Drugs in Patients with Alzheimer’s Disease.N Engl J Med 2006;355: 1525-38.

  3. Weise B.Geriatric depression: The use of antidepressants in the elderly.BCMJ, Vol. 53, No. 7, September 2011, page(s) 341-347.

  4. Maust DT, et al. Antipsychotics, Other Psychotropics, and the Risk of Death in Patients With Dementia:Number Needed to Harm.JAMA Psychiatry. 2015;72(5):438-445.

  5. Inouye S, et al. Delirium in Older Persons. N Engl J Med 2006;354:1157-65.

  6. Markowitz JD and Narasimhan M. Delirium and Antipsychotics: A Systematic Review of Epidemiology and Somatic Treatment Options. Psychiatry (Edgemont) 2008;5(10):29–36.

  7. Perkisas S and Vandewoude M. Ramelteon for Prevention of Delirium in Hospitalized Older Patients. JAMA Psychiatry. 2014;71(4):397-403.

  8. Fong TG, et al. Delirium in the Elderly:Diagnosis, Prevention and Treatment. Nat Rev Neurol. 5, 210-220 (2009).

  9. Kirino E.Use of aripiprazole for delirium in the elderly: a short review. PSYCHOGERIATRICS 2015; 15: 75–84.

  10. Maldonado JR. Delirium in the Acute Care Setting:Characteristics, Diagnosis and Treatment. Crit Care Clin 24 (2008) 657–722.

  11. Bourgeois JA, et al. Adjunctive Valproic Acid for Delirium and/or Agitation on a Consultation-Liaison Service: A Report of Six Cases. J Neuropsychiatry Clin Neurosci 2005; 17:232–238.

  12. Attard A, et al. Delirium and its Treament. CNS Drugs 2008; 22 (8): 631-644.

     

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Karen Padua, DO

Aurora Health Care, Milwaukee, WI

 

Michael Malone, MD

Aurora Health Care, Milwaukee, WI