Treatment ofAgitationintheElderly

McGillRefresherCourse– December2020

FadiMassoudMDFRCPC,Internist-Geriatrician

CentreHospitalier CharlesLeMoyne &Institut Universitaire deGériatrie deMontréal

DISCLOSURES

• NoConflicts ofInterest toDisclose

Objectives

Asaresultofattendingthissession,participantswillbeableto:

• Discussthedifferentialdiagnosisofagitation

• Developastructuredapproachtothemanagementofdeliriumandneuropsychiatricsymptomsofdementia

• Discusswhenandhowtousethepharmacologicalapproachindeliriumandneuropsychiatricsymptomsofdementia

Outline

• Definition• Differential diagnosis• Delirium• Neuropsychiatric symptoms ofdementia (BPSD)• Discussion/Q&A

Introduction

• Agitation:characterized byinappropriateverbal,vocal,ormotoractivitynotjudgedbyanoutsideobservertoresultdirectlyfromperceptibleneedsorconfusionoftheagitatedindividual.

• DifferentialDiagnosis• Medical:delirium• Psychiatric

• Anxiety disorders• Psychotic disorders• Mood disorders (Mania)

• Neuropsychiatric• NPSSx indementia – Behavioral ofPsychological Symptoms ofDementia (BPSD)

DELIRIUM

Delirium

• Commonmedicalcomplicationofhospitaladmission– Upto30%ofmedicaladmissionsand50%ofsurgicaladmissions

• Increasedmorbidity– Othermedicalcomplications,lengthofstay,functionaldecline

• Increasedmortality• Simpletodiagnose• Preventable

DeliriumDiagnosisConfusionAssessment Method(CAM)

• 1)Acuteonsetandfluctuates– Priorknowledgeofpatientcondition,serialfollow-up(nurses’notes)

• 2)Inattention– Daysoftheweek(ormonths)inreverseorder,serialsubsractions,etc.

• 3)Disorganizedthinking– Incoherence/Delusions/Hallucinations

• 4)Alteredlevelofconsciousness– (Hyper)vigilant– Alert– Lethargic– Stuporous– Comatose

• Diagnostic=1+2+(3ou 4)• Se:94%à100% Sp:90%à95%

Inouye et al., Ann Int Med, 1990

DeliriumSub-types

Hosker Cetal,BMJ2017

DeliriumRisk/Predisposing Factors

• Preexistingcognitiveimpairment• Multiplecomorbidconditions,includingdepression• Polypharmacy• Impairedsensoryinput(e.g.,vision,hearing)• Impairedfunctionalability(lessautonomousinADLsandIADLs)• Historyofalcoholmisuse• Malnutrition• Anemia• Electrolyteabnormalities

DeliriumPrecipitating Factors /Causes

• D rugs• E lectrolytes• L ack ofdrugs (withdrawal syndromes)• I nfections• R educed sensory inputs/Restricted mobility• Intracranial• U rinary retention• M edical

• Often multifactorial !• Medical emergency

DeliriumManagement

History

Physical examination

Targeted Investigation

Medication Review

Treatment

Causal Non-pharmacological Pharmacological

DeliriumNon-Pharmacological Approach

• Indicatedinallpatientswithdelirium• InsureSafety/Supervision:

– Closertonurses’desk• ControllevelofStimulation:

– Privatesitters,privateroom– Quietenvironment(optimisesleep)

• Helpwithorientation:– Familymembers,pictures– Eyeglasses,hearingaids,calendar– Simpleandreassuringcommunication

• Basicneeds– Earlymobilisation:avoidrestraints,indwellingcatheters,venousline,etc.– Nutrition/hydration/elimination

DeliriumPharmacological Treatment

• Severeagitationandagressivity• Delusionsandhallucinations• Low-dosehaloperidol

– Fewanticholinergicsideeffects– Lesssedating– PO/SC/IM/IV– Extra-pyramidalsideeffects– PotentialriskforincreasingQTinterval(IV)– MostoftenusedPRN:0.25à0.5mg(SC/PO)toberepeatedq60minutesad2mg/24h(regularVS)

Pharmacological TreatmentAtypical Antipsychotics – Geriatric Doses

• Anti-serotoninergic,rapid dissociationfrom D2receptors• Less EPside effects• BUT….Associatedwith :increased risk ofmortality,stroke,aspiration

pneumonia,cognitivedecline,metabolic syndrome,falls,etc.

• Risperidone [Risperdal]:0.25-2mg/d,in1or2doses• Olanzapine[Zyprexa]:2.5-10mg/d,in1or2doses• Quetiapine[Seroquel]:25-200mg/d,in1or2doses• Aripiprazole[Abilify]:1‒10mg/d,in1or2doses

• ( Clozapine [Clozaril]:12.5-75mg/j,in1or2doses)

Pharmacological TreatmentExampleofprescription

• Risperdal0.25mg(to0.5mg)POq12h

• Haldol0.25mg(to0.5mg)POorSCPRN,ifpatientveryagitated,repeatableq60min,max=4doses/24h

Pharmacological TreatmentBenzodiazepines

• Secondlinetreatment:– Riskofexacerbatingagitationandconfusion(paradoxicaleffect)– Oversedation– Falls

• Traitement ofchoicefor:– BZDwithdrawal– EtOHwithdrawal

• Asacomplementtoneurolepticsinresistantagitation• Agentofchoice:lorazepam[Ativan]

– Withdrawalsyndromes:0.25mg- 1mg(PO,SC,IM,IV)q4-6hPRN– 0.25à0.5mg(SC,IM,IV)inassociationwithhaldol inresistantagitation

• Avoidlong-actingBZD:– Chlordiazepoxide[Librium]– Diazepam[Valium]

DeliriumConclusions

• Commonmedicalcondition• Potentialemergency• Associatedwithsignificantmorbidityandmortality• Diagnosismadesimplebyoperationalizedcriteria(CAM)• Non-pharmacologicalapproachinallpatients• Targetedpharmacologicalapproach• Importantroleforprevention

Neuropsychiatric Symptoms ofDementia

Behavioral andPsychological Symptoms ofDementia (BPSD)

BPSD

• 80to97%ofAlzheimer’spatientswillsufferfromBPSDatsomepointintheirdisease

• Fastercognitiveandfunctionaldecline• Institutionnalization• Increasedmortality• Decreasedqualityoflife• Increasedcaregiverburden(anxietyanddepression)• Increaseduseofphysicalandchemicalrestraints• Increasedcosts

BPSD• Delusions• Hallucinations• Agitation• Depression• Anxiety• Euphoria• Apathy• Disinhibition• Irritability• Aberrantmotor behavior• Sleep• Appetite

Agitation

Rabheru K,CGSJCME2019

BPSD/AgitationGeneralApproach

Clinical Questions• New medical problem?• Pain?• Medication side effects ? • Substance (prescribed or not) abuse ?• Exacerbation of psychiatric condition?• Expression of a basic need?

– Hunger, thirst, need to use the bathroom, rest (quality of her sleep?), boredom, isolation, hearing or vision impairment

Questionsaboutenvironment• Adequatelevelofsensorystimulation?• Adequatelevelofcognitive/social

stimulation• Dailyroutinewelladaptedtocurrentstate

ofhealth?• Spaceandtimereference?• Impactofbehaviororpresenceofother

people?• Nursingstaff’sapproachpersonalized?

Behavior Description

• What?- Identify/describetheproblematicbehavior• When?• Where?• Withwhom?• Warningsigns?• Interventions?

BehaviorObservationGrid

BPSD/AgitationNon-Pharmacological Approach

Mainstayofmanagement

• Caregiver(familyandinformal)– Education(responsetodiscomfort,unmetneeds,orattemptstocommunicate),supporttherapy– BPSDmanagementtraining:« GentlePersuasiveApproach »

• Patient– Individualizedapproach– Sensorystimulation:musictherapy,aromatherapy,lighttherapy,multisensorystimulation(Snoezelen),etc.– Socialcontact:structuredsocialinteractions– Structuredactivities:adaptedphysicalexercise,walkingprogram,recreationtherapy(pastinterests)

• Examples– Soothingenvironment/optimallevelsofstimulation– Respondtopatientsandde-escalatebehaviors(e.g.,distraction,givingpatientsclearinstructionsand

simplechoices,notrewardingthebehaviors,etc.)

BPSDNon-Pharmacological Approach

Rabheru K,CGSJCME2019

BPSD/AgitationPharmacological Approach

Indications• Behaviorofmoderateorsevereintensity• Posesahealth/safetyriskforthepatientorothers• Thebenefitsofpharmacologicaltreatmentoutweightherisks

Generalprinciples• Startlow,goslow…butgo• Onepharmacologicalagentatatime• Checkoftenforsideeffects• Completeresponsecantake2to6weeks• Considerchangingagentsifnoevidenceofefficacy• Attemptprogressivewithdrawalafterthepatienthasbeenstablefor3to6months.

BPSDPharmacological Approach

Behaviors usually not responsivetoRx

• Resisting care(hygiene,gettingdressed)

• Wandering• Runningaway• Repetitive screams• Repetitive movements• Accumulationrituals• Verbaldisinhibition

Behaviors usually responsivetoRx

• Agitation/aggression• Psychosis• Anxiety• Depression• Sleep problems• Apathy?• Disinhibited sexual behaviors?

AgitationPharmacological Approach

• Empiric treatment ofpain• Selective Serotonine RecaptureInhibitors (SSRIs)• Antipsychotics• Cholinesterase Inhibitors• Memantine

AgitationPharmacological Approach

• EmpiricTreatmentofpain– Painiscommon,underdiagnosedandundertreatedindementia– Routineacetaminophen(Max:3gdaily)– Topicaltherapies:diclofenac,lidocaine– Neuropathy:duloxetine,gabapentin,pregabalin(carefully..)

• SSRIs– First-linetreatmentformildsymptoms:irritability,lability,anxiety,depressedmood,etc.

– 4-6weeksforclinicalresponse

AgitationPharmacological Approach

Antipsychotics• Severeagitationandaggressiveness• Atypicalantipsychotics

– Risperidone:approvedindicationinCanada• Typicalantipsychotics

– Inemergencycases.• Sideeffectprofile/Riskofstroke/Riskofdeath

Pharmacological TreatmentAntipsychotics – Side Effect Profile

https://www.grepmed.com/images/3725/

AgitationPharmacological Approach

• Cholinesterase inhibitors (donepezil,rivastigmine,galantamine)– Prevent BPSDwhen started inmild-modAD– Possibleefficacy inreducing apathy /irritability– Ineffectiveforsevereagitation/agressivity– (ImprovevisualhallucinationsinDementiawithLewyBodies)– OccasionalworseningofBPSDwhenstopped

• Memantine– Possibleeffectinpreventingortreatingirritability,agitation,aggressivenessandpsychosis

– Casesofworseningagitationandhallucinationsreported– Dosagemustbeadjustedaccordingtocreatinineclearance

Questions/Comments

ClinicalCases

Case1

• 88yoladywhosuffersfrommoderateADwithnonBPSD- Residence• Admittedtothehospitalafterafallandlethippain• LeftintertrochantericfracturediagnosedinER• Openreductionandinternalfixation• AgitationandvisualhallucinationsstartingbeforetheOR• PO:resistanttonursingandPTinterventions,periodsofagitationalternatingwithperiodsofsomnolence,behaviourworseintheeveningandatnight

• Geriatricsconsultation

Case1

• Dx:mixed(hyper/hypoactive)delirium• R/oacuteMxcondition:infx,E+disturbance,cvsevent,etc.• Targettedinvestigation• Rxreview:forpain,nausea,sleep,agitation..• Optimizepaincontrol:acetaminophen- hydromorphone/oxycodone–avoidcodeine/morphine

• Deprescribe/rationalizeRxifneeded• Basicneeds:earlymobilization,nutrition,hydration,elimination• Non-Rxapproach:ensuresafety,optimizeorientation,stimulation• TargetedRx:PRNvsregular– atypicalantipsychoticBID+PRNhaloperidol

Case2

• 80yogentlemanwithmild-modADlivingwspouseonFU• Graduallyprogressivecognitiveandfunctionaldecline• Irritableandverballyagressive,especiallywhenconfrontedtohiscogndeficits– NophysicalagitationnorpsychoticSx– SleepOK

• Wifewellawareofnon-Rxapproaches(AlzhSocietytrainingsessions):de-escalation,distraction,enjoyableactivities,physicalactivity(walkingqday)…ptstillirritableandagressiveonadailybases

• Wifeisshowingsignsofexhaustion..• Whatwouldyourecommend?

Case2

• Dx:BPSD(verbalaggressiveness,irritability)• r/oanycontributingmedicalcondition(ormedication)• Enforcenon-Rxapproach• Enlistassistance:communityressources,family..• RxApproach

• SSRI:citalopram,sertraline• SNRI:venlafaxine,duloxetine(pain)• NaSSA(noradrenergicspecificspecificserotoninergicagent):mirtazapine(optimizesleep/appetite)

• Low-doseatypicalantipsychotic?

Case3

• 85yoladywithmod-sevAD– NHx9months• Sevcognitiveandfunctionalimpairment• Physicallyagressiveandagitatedduringpersonalcare(bathing):resists,screams,hits..

• Walks++andtendstowanderinotherresidentsrooms• Otherwisecalmandcooperative• Whatwouldyourecommend?

Case3

Résistancetopersonalcare• Environment:

• Ensure thebathroom iswarm / private• Appropriate furnishings/welcoming lookrather than a

sterile/austere look.• Encouragetheperson toholdonto to railsorsolid object

for security• Useashower chairorbath seat• Ensure personal preference forbathing timesandmethods

• Communication• Encouragepatientparticipation byoffering simple,one-

stepinstructionsandactions• Talkaboutpleasant andnon-threatening topics while

providing care

• Other:preferredmusic,reminiscences,etc.

• Inresistantcases:antipsychoticuse30minbeforeactivity

Wandering• Ensuresafeenvironmentforwalking

• Concealexits

• « Stopsigns »ondoorsofotherresidents’rooms

• AvoidRxandrestraints:seldomimprovebehaviourandincreaserisksoffalling

• BPSD:resistance/agitationduringpersonalcareandwandering• Non-Rxapproachiskey