Rational Treatment of Agitation
and Behavioral Symptoms in
Patients with Dementia
December 2, 2011
Indiana Osteopathic Association
30th Annual Winter Update
John J. Wernert, M.D., MHA
Geriatric Psychiatrist
Medical Director, Medical Management
Wishard Hospital
“The singular benefit of old age is to see life whole and know
it’s natural course”
Philosopher Arthur Schopenhauer
Faculty Disclosure
John J. Wernert, M.D, MHA
Consultant:



Various ECF/LTC facilities
Federally Qualified Health Centers
Archdiocese of Indianapolis
Speaker’s Bureau:

Sunovion
Ownership Interest:

PDA, LLC
Goals and Objectives
Understand the demographic shifts in
America and the challenges of treating
neurodegenerative disorders
Gain Knowledge of the Differential Diagnosis
of Dementia in Elderly patients
Discuss the unique challenges of treating
agitation and behavioral issues in dementia
Discuss various pharmacological and
behavioral interventions
Key Points
Neurodegenerative disorders are increasing rapidly, and
will present the greatest health challenge for an already
overburdened American health system
Psychosis and agitation are common symptoms in
elderly patients, especially in patients with dementia
Physical conditions, physical discomfort, and medication
side effects need to be ruled out as causative factors
Treatment involves caregiver education and support,
patient-centered behavioral interventions, milieu
adaptations, and pharmacotherapy
It is important to consider drug and nondrug
interventions that will provide the most effective and
tolerable relief of patient symptoms and decrease
caregiver burden.
The Perfect Storm = The Aging American Population
and the Inevitable Tsunami of Health Care needs that
will overwhelm our Society
Healthcare
Expenditures in America
17.2% GDP in 2009
Current projections 19.5% by 2017
$2.5 trillion spent on all of healthcare
$8087 per person
$557 billion on physician care and other
clinical services
Healthcare Coverage in
America
52 million uninsured (18% of population)

Fastest growing segment of uninsured are
those making over $60,000/yr
83 million (27.8%) covered by
government programs
166 million (55%) private or employerbased insurance

Less than 9% buy their own insurance
What about 2016?
CMS projects $4 trillion spent on HC
$2.2 trillion paid by Gov’t payors
20% of US GNP
$800 billion attributed to physician care
$1.3 trillion on hospital care
$497 billion on prescription drugs
The Cost of Brain
Disorders
U.S. Society = $430 Billion annually
18 % of the average American income is
devoted to treating Brain diseases
50% cost is Dementias
Psychiatric Illnesses = $160 Billion
Direct and indirect costs of Alzheimer’s and
other dementias in 2010 will amount to more
than $172 billion.
By 2015, Medicare is projecting to spend
$189 billion in DIRECT COST on
beneficiaries with Alzheimer’s and other
dementias.
Demographics of
American Elderly
“Old” old - Born before 1925
Elderly - 1925 – 1946
Baby Boomers - 1946 - 1964
“Old” old Americans
Period of Austerity – usually raised
on farm, healthy living
Resourceful
Learned to be resilient and do without
Good Genes
Stress made them stronger (natural
selection)
Avoid Healthcare – tough it out
Predominant Attitudes:

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Perseverance
Conservative
Survivors
900 years old!
Nonagenarians
90 yo have tripled since 1980
1.9 million according to 2010 census
1900 = less than 100,000
Projected to increase to 8.7 million by 2050
3:1 female to male
37.3% live alone
37.1% live with family
23 % live in nursing homes
Median income $14,700 – ½ from SS

Reported in Indianapolis Star 11/18/11
The American Elders
(the Greatest
Generation)
Lived through the “tough times”
Good Genes
Disposable income
Less healthy living
Honorable Commitments
Wealth-Builders and Savers
Attitudes:
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Patriotic
Family oriented
Selfless
Baby Boomer
Demographics
77,702,865 Americans born 1946-1964
28% single ( 16% divorced, 2.9 %
widowed, 9.1% never married)
Baby Boomers
Raised in times of largess (more is better)
Exposed to fewer social stressors
Technology blossoms
Wealth Spenders
EgoCenticism
Love healthcare
Attitudes:

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“me” generation
Liberal
Quality of Life and Retirement are important goals.
Caring for the Elderly is
expensive
In 2009, the average private room in a
nursing home cost $219 daily.
Assisted living costs averaged $3,131
monthly.
Home health aides averaged $21 per
hour.
Adult day care services averaged $67
daily.
Long Term Care
Insurance
About 60 percent of individuals over age 65 will
require at least some type of long-term care services
during their lifetime.
About 40% of those receiving long-term care today
are between 18 and 64.
Premiums have risen dramatically in recent years
even for existing policy holders.
Coverage costs can be expensive, especially when
consumers wait until retirement age to purchase LTC
coverage.
Don’t count on the Government !

Obama Administration announces HHS Will Not Implement
CLASS Long-Term Care Insurance Plan – Oct 2011
The Crisis of the Aging
Human Brain – Genes,
Stress and Lifestyle
Alzheimer’s Statistics
An estimated 5.3 million Americans of all ages have
Alzheimer’s disease (2010).
5.1 million people aged 65 and older (13%) and
200,000 individuals under age 65 who have youngeronset Alzheimer’s.
The Alzheimer’s Association estimates that there are
500,000 Americans younger than 65 with Alzheimer’s
and other dementias. Of these, approximately 40
percent are estimated to have Alzheimer’s.
By 2030, all baby boomers will be at least 65 years
old. That year, the number of people aged 65 and
older with Alzheimer's is expected to reach 7.7
million.
Who cares for Dementia
Patients?
70% are cared for in the community
Almost 11 million Americans provide unpaid care for
a person with Alzheimer’s disease or another
dementia.
In 2009, they provided 12.5 billion hours of unpaid
care, a contribution to the nation valued at almost
$144 billion.
Caring for a person with Alzheimer’s or another
dementia is very difficult and expensive.
Family and other unpaid caregivers experience high
levels of emotional stress and depression as a result.
Caregiving also has a negative impact on their
health, employment, income and financial security.
Physicians Perspective –
community-based care of
Dementia patients
Recurring themes
 insufficient time
 difficulty in accessing and communicating
with specialists
 low reimbursement
 poor connections with community social
service agencies, and lack of
interdisciplinary teams.
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J Gen Intern Med. 2007 Nov;22(11):1487-92. Epub 2007 Sep 7.Practice constraints, behavioral problems,
and dementia care: primary care physicians' perspectives.
Hinton L, Franz CE, Reddy G, Flores Y, Kravitz RL, Barker JC
Challenges:
Physicians often feel challenged in caring for
dementia patients,
 particularly those who are more behaviorally
complex
 Because of time and reimbursement constraints
as well as other perceived barriers.
 Lack of effective educational interventions (for
families and physicians)
 Caregivers breaking down
 Constraints may lead to delayed detection of
behavior problems, "reactive" as opposed to
proactive management of dementia, and
increased reliance on pharmacological rather than
psychosocial approaches.
What is agitation?
Irritability, frustration, excessive anger
“Blow ups” out of proportion to the cause
Constant demands for attention and
reassurance
Repeated questions or telephone calls
Stubborn refusal to do things or go places
followed by explosive behavior
Constant pacing, searching, rummaging
Yelling, screaming, cursing, threats
Hitting, biting, kicking
Agitated Behaviors
Agitated behavior is common during
Alzheimer's disease (AD) progression, with
symptoms that may include delusions,
hallucinations, and aggression.
Behavioral changes can greatly increase
caregiver distress.
Primary reason for institutionalization.
Treatment that delays or decreases these
symptoms may ease caregiver burden and
postpone institutionalization of the patient.
Honing in on the
problem
Before initiating treatment, the physician must
rule out any potential contributing factors,
such as medical disorders, physical
discomfort, medication effects, and
preexisting psychiatric illness.
Target behaviors must then be identified in
order to initiate appropriate treatment
(pharmacologic and/or environmental) that is
aimed at those behaviors.
Prevalence of Symptoms of Psychosis and
Neuropsychiatric
Inventory
Apathy
Depression
Item Dementia
(n = 329)
27.4
23.7
No Dementia
(n = 673)
3.1
7.0
Agitation/aggression
Irritability
Delusions
23.7
20.4
18.5
2.8
4.5
2.4
Anxiety
Aberrant motor behavior
Hallucinations
17.0
14.3
13.7
5.6
0.4
0.6
9.1
0.9
0.9
0.3
Disinhibition
Elation
Adapted from Lyketsos CG, et al. Am J Psychiatry 2000; 157: 708
.
Differential Diagnosis of
Behavioral Problems
Dementing disorders
Delirium
Medical illness
Iatrogenic
Psychosocial triggers
Physical discomfort
Primary psychiatric illness

Adapted from American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV). 4th Ed. Washington, DC, American
Psychiatric Association, 1994.
Delirium
“an acute disorder of attention and
cognition” (de lira “off the path”)
Can persist for days to weeks
Other terms used include organic brain
syndrome, metabolic encephelopathy,
toxic psychosis, acute mental status
change, exogenous psychosis,
sundowning
Delirium in the elderly
Delirium is common in older inpatients, associated with
poor outcomes, and commonly missed or
misdiagnosed
Underlying dementia is risk factor

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25% delirious are demented
40% demented in hospital are delirious
Prevention is the best approach
Management involves treating underlying causes,
minimizing medications, supportive care, and
avoidance of restraints when possible
ICU delirium poses particular challenges and risks for
elderly patients (CCU)
Delirium versus
Dementia
Delirium
Rapid onset
Primary defect in
attention
Fluctuates during the
course of a day
Visual hallucinations
common
Respond rapidly to
neuroleptics
Dementia
Insidious onset
Primary defect in short
term memory
Attention often normal
Does not fluctuate
during day
Visual hallucinations
less common
Response to meds
inconsistent
Various types of
Dementia
DAT vs SDAT
Vascular
Lewy Body Dementia
Parkinson’s
Pick’s
Demylinating diseases (MS)
Infectious/Metabolic (HIV, cancer)
Senile Dementia of the
Alzheimer’s type (SDAT)
Is this what Alzheimer Described?
Early onset of Memory Deficits
Absence of Neurologic Deficits
No CVA or injury on CT
Makes up 70 % of Dementia Pt’s
>5 million elderly Americans currently Dx
Already 6th leading cause of death
Vascular Dementias
Onset: Abrupt
More common in males
Progress: Stepwise
History: TIA, strokes
Clinical examination:
Evidence of atherosclerosis
 Neurologic deficits
 + CT/MRI findings

Dementia With Lewy
Bodies
Fluctuating course, rapidly progressive
Hallucinations are detailed and prominent
Psychosis, delusional or paranoid ideation
Mild extrapyramidal signs
Cortical deficits: 4 As (amnesia, anomia,
agnosia, apraxia)
Subcortical deficits: attention, verbal fluency
Neuroleptics may aggravate symptoms
Parkinson's Disease and
Dementia
About 25% of patients with Parkinson's
disease will develop serious dementia
Impaired executive functions
Psychomotor retardation, depression
Hallucinations, delusions
Speech disturbances
Low educational or socioeconomic status
Dopamine precursors may trigger confusional
states or delirium
Neuroleptics may worsen condition
Development of
Agitation
More prevalent in later stages
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“Prisoner of the Present”
Misinterpretations
Medical co-morbidities worsen

Pain
Frontal lobe involvement
Disinhibited behaviors

Sexualized behaviors
“Once mean, always mean”
Sundowning = majority requests for Rx
Psychosis and Agitation:
Management
Reassure, distract patient; provide structure
Identify and adjust environmental triggers
Assemble an interdisciplinary treatment team
Educate patient, family, and staff about
treatment plan, including goals of
pharmacotherapy
Monitor and evaluate pharmacologic
interventions
Ensure support for the caregiver to prevent
burnout
Treating Psychotic
Symptoms
Delusions or hallucinations appear in 30% to
50% of patients with AD, and up to 70%
demonstrate agitated or aggressive
behaviors.
In findings published in 2006 in the New
England Journal of Medicine, atypical
antipsychotics showed "modest efficacy" in
decreasing behavioral symptoms in the
CATIE-AD patients after 12 weeks compared
with placebo. However, they also showed
more treatment-related adverse events.
Pharmacotherapy
Antipsychotics

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Typicals
Atypicals
Mood Stabilizers (AED’s)
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Depakote
Anxiolytics
Sedatives
Hypnotics
Antidepressants
Risks of “chemical
restraints”
ISBOH Guidelines
Accreditation agencies frown on
perceived “overuse” of medications
Family resistance
Side effects
May worsen target symptoms
Atypicals:
Have become the standard “go to” class
May actually worsen cognitive decline
Increased risk of stroke and CVA events
(black box warning)
Metabolic Syndrome also a risk for
elderly patients
Atypical Antipsychotics
Risperidone
Olanzapine
Quetiapine
Ziprasidone
Aripiprazole
Clozapine

All have black box warning – CVA risk in elderly
Anticonvulsants
May have efficacy for explosive,
paroxysmal nonpsychotic agitation
Most effective in frontal lobe impairment
Sodium valproate
Carbamazepine – less commonly used
Newer agents unproven
Valproic Acid (Depakote)
Great choice for disinhibited behaviors
Calming without being excessively sedating
Easier to use;
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Depakote ER
Depakote EC bid
Depakene syrup
Depakote sprinkles
Starting dosage: 50 mg / kg
Blood levels helpful - can titrate to serum
level of 80 – 120
Generics available
Anxiolytics
Benzodiazepines
Ativan - # 1 fall risk
 Long acting better (Clonazepam)

Vistaril – anticholinergic delirium
Buspar – minimal benefit
Antidepressants
SSRI’s
 TCA’s

Sedative/Hypnotics
Can be helpful for sleep regulation
Low dose Trazodone

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25 – 50 mg q 8 pm
Give at 5 pm if sundowning an issue
Remeron

7.5 mg = increase sedation / appetite
Vistaril + Benadryl – avoid
Melatonin 3 -6 mg may be helpful
Minimize use of Ambien, Lunesta and BZ
hypnotics
Medications used too
often?
“Much of medication use is due to the lack of
interest, willingness, funding, or ability to provide
psychosocial or environmental interventions to
patients with agitation, aggression, and
psychosis who have dementia.”
“Despite the widespread awareness of adverse
consequences, we can only infer that atypical
antipsychotics continue to be prescribed for
dementia treatment because there is a lack of
alternatives and there is a perceived clinical
benefit by care providers.”

Am J Psychiatry. 2011;168:831-839, 767-769. Abstract Editorial
Behavioral Interventions
Identify and reduce antecedents
Has little effect on overall functioning
Can reduce problem behaviors such as
wandering, inappropriate voiding and
exit seeking
Work towards strict daily routines
Emotion-oriented
interventions
Reminiscence therapy
Memory corner
 Memory book

Sensory integration

Snoezelen room
Simulated Presence therapy
Validation therapy
Cognition-oriented
Cognitive retraining
Reality orientation
In later stages, may result in more
frustration
Has very limited utility in decreasing
agitation
Stimulation-oriented
Primarily helps patients daily routine
Exercise
 Recreational activities
 Art therapy
 Music – age appropriate
 Pet therapy
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Important Change: Limit
Antipsychotics
For patients who have neuropsychiatric symptoms,
such as agitation, delusion, hallucinations, and
aggression, there is stronger evidence that nondrug
treatment should be tried first and that real efforts
should be made to limit the use of antipsychotics in
all settings — at home and in the long-term-care
setting. "That is the most important way the
guidelines will change practice."
“Real efforts need to be made to make sure that
when antipsychotics are prescribed, they are both
necessary and effective; when they are not effective,
they should be discontinued."
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2007 second addition APA Treatment Guidelines Updated Guidelines for
Treating Patients With Dementia
Supplement to American Journal of Psychiatry
If you must use
atypicals:
Be prepared to do Gradual Dose
Reductions (GDR’s) – even if patient is
doing well
Start low
Write for automatic stop dates
Don’t assume the patient is better solely
because of medication
Continue to trial behavioral interventions
Summary
Patients with dementia commonly become
restless and agitated
Environmental triggers, medical disorders,
and medication side effects need to be ruled
out as contributing factors
Treatment approach must include appropriate
nondrug interventions, as well as thoughtfully
chosen medications
Primary caregiver requires attention, support,
and respite
Unfortunately, medications have become the
mainstay of treatment. Use short term