Psychosomatics 45:177-178, April 2004
© 2004 The Academy of Psychosomatic Medicine
Agitation in Patients With Dementia
Edited by Donald P. Hay, M.D., David T. Klein, Psy.D., Linda K. Hay, R.N., Ph.D., George T. Grossberg, M.D., and John S. Kennedy, M.D., Washington, D.C., American Psychiatric Publishing, Inc., 2003, 272 pages, $43.95, ISBN 0-88048-843-3
Susan K. Ball, M.D.
Behavioral problems in elderly patients with dementia present one of the most difficult challenges for psychiatrists in consultation/liaison, outpatient practice, and long-term care settings.
Agitated behavior is one of the main reasons that caregivers are forced to place a patient with dementia in a long-term care setting. The behaviors bring risk of injury to caregivers, innocent bystanders, and health professionals. The behaviors indicate a high level of distress in the patient.
Hospitals accrue a high burden of cost by having to provide one-on-one supervision to elderly agitated patients.
In the not-too-distant past, the widespread use of haloperidol as a "chemical restraint" for these behaviors caused tremendous morbidity. All behaviors were lumped together and treated as a single entity. Thanks to the Omnibus Reconciliation Act of 1987, the use of chemical restraints decreased in nursing homes. Facilities were forced to improve psychiatric and behavioral care of their residents. With the explosion in the quality and breadth of psychopharmacology in recent years for disorders across the lifespan, and the dedication of researchers in the field of geriatric psychiatry, there are now multiple treatment modalities available to the psychiatrist. Along with these modalities comes the difficulty of how and what to choose for a given patient.
This elegant book tells you exactly what is known about agitation in dementia. It is replete with a wealth of references at the end of every chapter. The authors are some of the leaders in the field.
The first chapters cover definitions and theory, epidemiology, and neurochemistry as well as the use of rating scales. There is a clear range of agitated behaviors, which must first be categorized. They break down into the verbally nonaggressive, the verbally aggressive, the physically nonaggressive, and the physically aggressive. Twenty-eight separate behaviors are included in these definitions. It is from the behaviors in these categories that have come the more commonly used rating scales for agitation in dementia. Epidemiological studies have observed a prevalence of agitated behavior of 66.5% in patients with advanced dementia. There is a very interesting chapter on the complex neurobiology of agitation, suggesting a complex interaction of both biochemical and structural changes in the brain rather than structural changes alone.
Chapter 5 covers the differential diagnosis of agitation looking at delirium, depression, psychosis, and anxiety. The author points out the overlap of cognitive and psychiatric diagnoses and the complexity of psychiatric diagnosis in the presence of dementia.
Chapters 6–9 present the nonpharmacologic interventions. They include the assessment and management of agitation in nursing home residents. There are suggestions on helping staff manage the environment in order to provide a calming effect on their patients. The chapter on psychotherapy in the demented patient reviews the current research on cognitive, behavioral, and psychodynamic therapies. These modalities have been found to "decrease depressed mood, improve life satisfaction, and bolster self esteem."
Chapters 10–15 review the spectrum of possible pharmacological interventions as well as ECT. They describe research that supports the use of one agent over another for specific behavioral subtypes. However, there is very little specific research on the use of mood stabilizers and antidepressants in dementia cited in these chapters. There is a detailed chapter on the role of antipsychotic agents in agitation. There is a helpful chart that lists the behaviors that are appropriate for antipsychotic medications under OBRA regulations and those that are not.
The final chapter reviews the legal and ethical issues affecting the life of the person with dementia as the disease progresses. It provides a brief review of ethical principles and the issues of capacity and guardianship.
Overall, this book gives the reader a comprehensive approach to this difficult subject. It is a useful resource book for those designing a residency curriculum in geriatric psychiatry and a helpful book for the clinician that is grappling with these difficult behaviors.
FOOTNOTES
Dr. Ball is Director of Geriatric Psychiatry at Crozer Chester Medical Center in Upland, Pa. She is a Clinical Associate Professor at Temple School of Medicine.
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