Managing Agitation in Elderly Patients With Dementia
by Jiska Cohen-Mansfield, Ph.D.
| Geriatric Times |
 |
May/June 2001 |
|
Vol. II |
|
Issue 3 |
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:
- There is a perception that people with dementia do not talk
rationally.
- It is contrary to caregivers' expectations as to what is appropriate. For
instance, a request for water may be discounted because "they just had a
drink."
- The person is unable to provide a complete description of what is troubling
them, for instance, where they are experiencing pain.
- The caregiver is listening to the literal, rather than the underlying,
message. For example, the patient may say that it is cold outside or that the
place is wet, when they mean that they are cold or wet.
- There are deficits in the caregivers' communication skills. For example,
the caregiver should be sure that the demented person can see them during a
conversation (Cohen-Mansfield, 2000; Ripich, 1994).
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.