Geriatric Psychiatry Research: Treating Agitation in The Elderly

As the relative increase in the elderly population becomes more pronounced, there is a greater awareness of some of the problems associated with providing adequate care for this population. There is an increased need for understanding the unique needs of providing for the physical, emotional and mental aspects of their care. While society is coming to grips with taking care of their chronic physical health conditions, there are also mental health issues such as dementia that must be contended with.

Dementia is an umbrella term used to describe neurological symptoms such as problems with speech (aphasia), difficulty with movement (ataxia), problems with memory (amnesia), deficits in recognition (agnosia) as well as problems with executive function which affects memory and problem solving (pp lecture notes, 2019). There are many different types of dementia based on the presentation as well as the possibility of having a combination of more than one type. This makes it challenging to provide the needed care for the affected patient. Alzheimer’s dementia is the most common type accounting for 50-70 % of the affected population. Other types include Vascular dementia usually seem with people who have had CVAs, Lewy body dementia which is seen with people who abnormal brain cells called Lewy bodies, Parkinson’s dementia is caused by the degenerative disease and accounts for approximately 5% of those diagnosed with the condition and fronto-temporal dementia is associated with the damaged neurons - tangles of protein in the brain (pp lecture notes, 2019).

In many cases, patients are brought into the Emergency Department with behavioral health emergencies such as psychoses - delusions, hallucinations, or disorganized speech and behavior. Here physical problems that present in this manner such as urinary tract infections must be ruled out. This is done by obtaining a thorough history and physical, laboratory and imagining studies are required for diagnosis and treatment. Other things that are considered include past psychiatric history, social and living situation and baseline cognition.

Possible culprits for the change in behavior include drug intoxication, drug withdrawal, brain mass, anemia, chronic kidney disease, hyperparathyroidism, hypoglycemia and thyroid disease to name a few. There is another important reason to obtain a psychiatric history as this helps in identifying serotonin syndrome and neuroleptic malignant syndrome. While these are relatively rare, they are potentially fatal psychopharmacologic emergencies (Bessey, et.al., nd).

Anxiety and depression must also be evaluated as these increase the risk for development of dementia. Geriatric patients often suffer from these conditions and early intervention is necessary to prevent the situation from seeming to spiral out of control. The Patient Health Questionnaire (PHQ-2, PHQ-9) and the Geriatric Depression Scale are useful tools to evaluate these conditions. “Late-life depression is associated with cognitive decline, disability, decreased quality of life, and higher mortality from medical conditions as well as increased risk of suicide attempts. Generalized anxiety disorder is the most common anxiety disorder in older adults, and approximately 50% of patients with generalized anxiety disorder develop the condition later in life” (Bessey, et.al., nd).

While the previous article deals with an Emergency Room situation, in a regular home or residential facility setting, it is important to quickly identify the underlying reason for the change in behavior of the patient/resident. Again, access to the most relevant history, physical, laboratory values, medications and baseline cognition information helps in quickly focusing on the likely reason for the noted change.

Dementia is a worldwide problem and the WHO projects that this will continue to mushroom over the coming years. It is believed that the majority of the world population of people with this condition live in a middle to low income countries and do not have access to the necessary resources or medications. Now there are scans that can help to identify volume loss as well as buildup of certain proteins that are associated with the disease. The difficulty with treating or preventing escalation of symptoms is related to the fact that by the time the symptoms such as forgetfulness and difficulty with executive function becomes apparent, the disease is already well established and the trajectory path has already been set. Medications such as Namenda, Aricept and Exelon can only help with cognition improvement and delay disease progression to a small extent (pp lecture notes, 2019).

Treatment of agitation in the elderly is an important topic that needs to be addressed especially in a residential facility setting. According to Cohen-Mansfield, (2015), agitation is usually linked to boredom/sensory deprivation, loneliness/need for social interaction, and need for meaningful activity. Caregivers understand that agitation can be related to physical problems such as pain, thirst, hunger, uncomfortableness tied to incontinence and environmental temperature extremes. The inability to see or hear properly are also contributing factors.

Some of the non-pharmacological interventions that are used to deal with agitation include social intervention of one-on-one interaction, simulated social interventions such as a lifelike doll and the sensory stimulation intervention of music. Other interventions include one-on-one social interaction, hand massage, music, video, walking, going outside, trips to the country side and the mall, food or drink, group activity, book presentation, ball toss and coloring or painting (Cohen-Mansfield, et.al., 2014).

There are times when pharmacological means must be used to reduced aggression and agitation for the safety of the patient, caregivers and others. The important thing is to avoid antipsychotics because of the cardiovascular effects on the health of the patient. It is suggested that SSRI/SNRI may be useful. Other suggested medications include beta blockers and valproate and to avoid benzoates as much as possible (pp lecture notes, 2019). In the article by Greve, DesJarlais & Ahmed, (2016), good outcome was achieved with the use of Prazozin. This seems plausible since patients suffering from some types of dementia e.g. Lewy Body dementia can experience hallucinations and Prazozin is used for night terrors in people suffering from PTSD.

I believe that as more research is done, there will be better ways of identifying the condition earlier and there will be other medications that are more effective in stabilizing and even reversing this. In the meantime, all effort should be made to deal effectively with the patients who become agitated and unable to make their needs known. With the projected increase in the elderly and in particular, those who are diagnosed with dementia, this relief is very necessary very soon.