Agitation is defined as "inappropriate verbal, vocal, or motor activity that is not judged by an outside observer to be an obvious outcome of the needs or confusion of the individual" (Cohen-Mansfield and Billig, 1986). The point of view of the person with dementia is frequently unknown, yet it is important to try to identify it in order to offer proper intervention. Agitated behaviors have been divided into three subtypes (Cohen-Mansfield et al., 1995b; Cohen-Mansfield et al., 1989a): aggressive behaviors; physically nonaggressive behaviors, such as pacing; and verbal agitation, such as constant repetition of sentences. Agitated behaviors can also be manifested in cognitively intact elderly people (Koss et al., 1997) and by those with psychiatric disorders other than dementia. Agitation in dementia is unique, however, in that its prevalence is linked with the progression of the dementia itself (Cohen-Mansfield et al., 1995a) and with the unique abilities and disabilities affected by this progression. For example, verbally nonaggressive behaviors are most prevalent in the middle stages of dementia when verbal abilities are still maintained, but the ability to use them effectively is diminished. In contrast, aggressive behaviors tend to occur in late stages of dementia, when verbal communication is severely compromised. Similarly, the quality of the behavior differs from that of other psychiatric symptoms. For example, aggressive behaviors are usually a response to actions by others, which the older person does not comprehend and does not want. To develop a coherent treatment plan for agitation, we need to understand its etiology (Table) (Cohen-Mansfield et al., 1992; Cohen-Mansfield and Werner, 1995). Treatment Principles Because the reason for agitation is not always apparent, the clinician may try to determine the need through observation, contact with different informants, and trial and error. Detection of need can be multi-tiered. For example, if a behavior can be linked to depression or hallucinations, one then asks what is causing the depression or hallucinations. Second-tier reasons for the depression may include boredom, and hallucinations may be a result of severe vision loss (Chapman et al., 1999; Cohen-Mansfield et al., 1998). It is important to focus on prevention, accommodation and flexibility as essential elements of intervention. The environment should be structured to prevent conditions leading to disruptive behaviors. Controlling temperature, facilitating activities, monitoring pain, and providing stimulation and social contact are ways to improve the environment. Agitated behaviors that fulfill the needs of older patients can be allowed, as long as they are demonstrated in a manner and setting that does not pose a risk to the patient and does not increase caregiver burden. An example would be to encourage patients to walk in a sheltered garden (Cohen-Mansfield and Werner, 1998b; Namazi and Johnson, 1992). Another example is an elderly woman found screaming next to the locked dining room door on her nursing home unit, wanting to get in. While the room held no objects of interest or entertainment, allowing her in would be appropriate, as she would neither be hurt nor cause harm. Caregivers must also be flexible in adjusting the older person's daily routine and environment based on the person's habits, identity, physical disabilities and remaining abilities. Flexibility in mealtimes and type of food, sleep times and type of bathing can all reduce conflict and ensuing disruptive behavior. Activities should be matched with patient's primary needs for social contact and meaningful and challenging activity. It is also important for patients to maintain the sense of identity they may have found through work and family roles (Cohen-Mansfield et al., 2000b). Current sensory and cognitive abilities, as well as the person's ability to comprehend, respond to and process information, should also be considered (Cohen-Mansfield, in press). Augmentation of sensory abilities should be simple, such as securing better-fitting eyeglasses, an auditory amplifier or better-fitting hearing aids. Assessing the Underlying Need Our research and clinical experience suggest several helpful approaches to clarifying the needs and wishes of the older person. Listen carefully, even when the information is not clear. Frequently the demented person is actually communicating, but caregivers discount this information for the following reasons:
Observing the patient for two to three minutes over several days and listening to any verbalizations can be very informative. Special attention needs to be paid to the antecedents of agitation, such as environmental conditions, and to affect, social contacts and verbal behavior (Cohen-Mansfield and Werner, 1995; Cohen-Mansfield et al., 1989b). Information about past pain and past preferred activities can be obtained from close relatives. Information about changes in behavior and affect and probable causes of discomfort can be provided by the caregivers. Various interventions should be attempted until one is found that fits the needs of the manifested behavior (Table). For example, if a person manifests verbal agitation when alone, one approach is to provide a social intervention and examine whether the behavior has been changed. Intervention Strategies Recent articles have described the difficulties in assessing pain in patients with dementia and have suggested innovative strategies (Feldt, 2000; Huffman and Kunik, 2000). The effect of hearing aids has been demonstrated in two studies in which fitting patients with hearing devices resulted in significant decreases in inappropriate behaviors (Leverett, 1991; Palmer et al., 1999). A number of approaches have been taken to improve sleep and thereby decrease agitation: use of bright light therapy (Mishima et al., 1994; Okawa et al., 1991), use of melatonin (Cohen-Mansfield et al., 2000a), increased exercise and a decrease in nighttime interruptions (Alessi et al., 1999). Patients also show improvement in eating or drinking with the use of enhanced light during meals (Koss and Gilmore, 1998). Finally, because physical restraints increase agitation (Werner et al., 1989), their removal may eliminate inappropriate behaviors. Loneliness The most straightforward approach to reduce loneliness calls for the person with the most positive relationship with the agitated individual to interact with the patient in a warm and loving manner. Unfortunately, this is not always possible. A number of alternative approaches have therefore been tried successfully, including: one-on-one interaction with a new caregiver (Cohen-Mansfield and Werner, 1997); videotapes of family members (Cohen-Mansfield and Werner, 1997); contact with animals (Churchill et al., 1999); massage therapy (Rowe and Alfred, 1999); and simulated presence therapy (Camberg et al., 1999), in which the family caregiver tapes their side of a telephone conversation that is played for the patient as a repeated phone conversation. Boredom Interventions to prevent boredom can be divided into those that provide stimulation, those that accommodate agitated behaviors and those that provide activities. Sensory stimulation includes music tailored for the patient (Gerdner, 2000), aromatherapy, touch therapy or Snoezelen sensory stimulation (Cohen-Mansfield, in press). Accommodating interventions include outdoor walks and the use of outdoor wandering areas (Cohen-Mansfield and Werner, 1999; Cohen-Mansfield and Werner, 1998b; Namazi and Johnson, 1992). Books and pamphlets can be provided for patients to handle (Cohen-Mansfield and Werner, 1998a) and activity aprons with buttons, threads and other articles sewn on can be provided, so that patients can fiddle with these, rather than with their own clothing or with harmful materials. Structured activities can reduce or prevent agitation. For some individuals, it is important to provide a meaningful activity, such as folding towels or kneading dough (Hellen, 1998; Russen-Rondinone and DesRoberts, 1996). These interventions are just some of the possible ways to better treat people with dementia. They exemplify the concepts of prevention, accommodation and flexibility. Ultimately, the correct treatment involves understanding the person's needs and treatment options based on their abilities and preferences. This demands consideration, persistence and creativity from caregivers. Dr. Cohen-Mansfield is director of the Research Institute of the Hebrew Home of Greater Washington and professor of health care sciences and of prevention and community health at the George Washington University Medical Center and School of Public Health. References Alessi CA, Yoon EJ, Schnelle JF et al. (1999), A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve? J Am Geriatr Soc 47(7):784-791. Camberg L, Woods P, Ooi WL et al. (1999), Evaluation of simulated presence: a personalized approach to enhance well-being in persons with Alzheimer's disease. J Am Geriatr Soc 47(4):446-452 [see comment]. Chapman FM, Dickinson J, McKeith I, Ballard C (1999), Association among visual hallucinations, visual acuity, and specific eye pathologies in Alzheimer's disease: treatment implications. Am J Psychiatry 156(12):1983-1985. Churchill M, Safaoui J, McCabe BW, Baun MM (1999), Using a therapy dog to alleviate the agitation and desocialization of people with Alzheimer's disease. J Psychosoc Nurs Ment Health Serv 37(4):16-22. Cohen-Mansfield J (2000), Nonpharmacological management of behavior problems in persons with dementia: the TREA model. Alzheimer's Care Quarterly 1(4):22-34. Cohen-Mansfield J (in press), Nonpharmacologic interventions for inappropriate behaviors in dementia: a review and critique. Am J Geriatr Psychiatry. Cohen-Mansfield J, Billig N (1986), Agitated behaviors in the elderly. I. A conceptual review. J Am Geriatr Soc 34(10):711-721. Cohen-Mansfield J, Culpepper WJ II, Werner P (1995a), The relationship between cognitive function and agitation in senior day care participants. International Journal of Geriatric Psychiatry 10(7):585-595. Cohen-Mansfield J, Garfinkel D, Lipson S (2000a), Melatonin for treatment of sundowning in elderly persons with dementia_a preliminary study. Arch Gerontol Geriatr 31(1):65-76. Cohen-Mansfield J, Golander H, Arnheim G (2000b), Self-identity in older persons suffering from dementia: preliminary results. Soc Sci Med 51(3):381-394. Cohen-Mansfield J, Marx MS, Rosenthal AS (1989a), A description of agitation in a nursing home. J Gerontol 44(3):M77-M84. Cohen-Mansfield J, Marx MS, Werner P (1992), Agitation in elderly persons: an integrative report of findings in a nursing home. Int Psychogeriatr 4(suppl 2):221-240. Cohen-Mansfield J, Taylor L, Werner P (1998), Delusions and hallucinations in an adult day care population. A longitudinal study. Am J Geriatr Psychiatry 6(2):104-121. Cohen-Mansfield, Werner P (1995), Environmental influences on agitation: an integrative summary of an observational study. American Journal of Alzheimer's Disease and Other Dementias 10(1):32-39. Cohen-Mansfield J, Werner P (1997), Management of verbally disruptive behaviors in nursing home residents. J Gerontol A Biol Sci Med Sci 52(6):M369-M377. Cohen-Mansfield J, Werner P (1998a), The effects of an enhanced environment on nursing home residents who pace. Gerontologist 38(2):199-208. Cohen-Mansfield J, Werner P (1998b), Visits to an outdoor garden: impact on behavior and mood of nursing home residents who pace. In: Research and Practice in Alzheimer's Disease, Vellas B, Fitten LJ, eds. Paris: Serdi Publisher; New York: Springer Publishing Company, pp419-436. Cohen-Mansfield J, Werner P (1999), Outdoor wandering parks for persons with dementia: a survey of characteristics and use. Alzheimer Dis Assoc Disord 13(2):109-117. Cohen-Mansfield J, Werner P, Marx MS (1989b), An observational study of agitation in agitated nursing home residents. Int Psychogeriatr 1(2):153-165. Cohen-Mansfield J, Werner P, Watson V, Pasis S (1995b), Agitation among elderly persons at adult day-care centers: the experiences of relatives and staff members. Int Psychogeriatr 7(3):447-458. Feldt KS (2000), Improving assessment and treatment of pain in cognitively impaired nursing home residents. Annals of Long-Term Care: Clinical Care and Aging 8(9):36-42. Gerdner LA (2000), Effects of individualized versus classical "relaxation" music on the frequency of agitation in elderly persons with Alzheimer's disease and related disorders. Int Psychogeriatr 12(1):49-65. Hellen CR (1998), Alzheimer's disease: activity-focused care. Woburn, Mass.: Butterworth-Heinemann. Huffman JC, Kunik ME (2000), Assessment and understanding of pain in patients with dementia. Gerontologist 40(5):574-581. Koss E, Gilmore GC (1998), Environmental interventions and functional ability of AD patients. In: Research and Practice in Alzheimer's Disease, Vellas B, Fitten LJ, eds. Paris: Serdi Publishers; New York: Springer Publishing Company, pp185-192. Koss E, Weiner M, Ernesto C et al. (1997), Assessing patterns of agitation in Alzheimer's disease patients with the Cohen-Mansfield Agitation Inventory. The Alzheimer's Disease Cooperative Study. Alzheimer Dis Assoc Disord 11(suppl 2):S45-S50. Leverett M (1991), Approaches to problem behaviors in dementia. In: The Mentally Impaired Elderly: Strategies and Interventions to Maintain Function, Taira ED, ed. New York: The Haworth Press, pp93-105. Mishima K, Okawa M, Hishikawa Y et al. (1994), Morning bright light therapy for sleep and behavior disorders in elderly patients with dementia. Acta Psychiatr Scand 89(1):1-7. Namazi KH, Johnson BD (1992), Pertinent autonomy for residents with dementias: modification of the physical environment to enhance independence. American Journal of Alzheimer's Disease and Related Disorders and Research 7(1):16-21. Okawa M, Mishima K, Hishikawa Y et al. (1991), Circadian rhythm disorders in sleep-waking and body temperature in elderly patients with dementia and their treatment. Sleep 14(6):478-485 [see comment]. Palmer CV, Adams SW, Bourgeois M et al. (1999), Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting. J Speech Lang Hear Res 42(2):312-328. Ripich DN (1994), Functional communication with AD patients: a caregiver training program. Alzheimer Dis Assoc Disord 8(suppl 3):95-109. Rowe M, Alfred D (1999), The effectiveness of slow-stroke massage in diffusing agitated behaviors in individuals with Alzheimer's disease. J Gerontol Nurs 25(6):22-34. Russen-Rondinone T, DesRoberts AM (1996), Success through individual recreation: working with the low-functioning resident with dementia or Alzheimer's disease. American Journal of Alzheimer's Disease and Other Dementias 11(1):32-35. Werner P, Cohen-Mansfield J, Braun J, Marx MS (1989), Physical restraints and agitation in nursing home residents. J Am Geriatr Soc 37(12):1122-1126. |
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