Recent studies have focused on combining cholinesterase inhibitors with other medications. We also reviewed references of included articles to ensure that we performed a comprehensive review of available evidence. Most patients with dementia experience behavioral and psychological symptoms of dementia (BPSD) [4], ranging from nuisance behaviors that are not necessarily harmful to the patient or caregivers, such as calling out, repetitive questions, dysphoric mood, and delusions, to behaviors that pose immediate potential or actual harm to patients and caregivers, such as wandering and physical or sexual aggression towards others. XVI, Issue 1 However, it is recommended that while working through the main pathway prescribers should avoid introducing new acetylcholinesterase inhibitors or memantine to permit assessment of the effects of . A training program for managing agitation of residents in long-term care facilities: description and preliminary findings. 2003;11:194-203.26. van Weert JC. Nurs Res. Tariot PN, Schneider LS, Cummings J, Thomas RG, Raman R, Jakimovich LJ, et al. Furukawa K, Tomita N, Uematsu D, Okahara K, Shimada H, Ikeda M, et al. The current evidence base needs to be augmented with future research that focuses on real-world medication use alongside head-to-head evaluation of medication effectiveness rather than comparison to placebo. Randomized double-blind placebo-controlled multicenter trial of Yokukansan for neuropsychiatric symptoms in Alzheimers disease. Remington R. Calming music and hand massage with agitated elderly. 2.1. Cortical cholinergic function is more severely affected in parkinsonian dementia than in Alzheimer disease: an in vivo positron emission tomographic study. Behavioral and mood effects of Snoezelen integrated into 24-hour dementia care. Am J Geriatr Psychiatry. Yang MH, Lin LC, Wu SC, Chiu JH, Wang PN, Lin JG. Soto M, Andrieu S, Nourhashemi F, Ousset PJ, Ballard C, Robert P, et al. A great deal of research is still needed to evaluate these therapies more fully in combination with other therapies and in comparison with placebo or other active treatments.Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.1 Although music therapy reduces overall agitation to a greater degree than no intervention, individualized or preferred music seems to offer greater benefit than general calming or relaxation music in patients with dementia.2-6 The long-term benefits of this intervention remain unclear; one study found short-term improvements in agitation but no significant differences in outcomes between music therapy and standard nursing home care groups over the course of a year.7Animal-assisted activities and therapy use animals to encourage patient well-being, socialization, and mental and sensorimotor stimulation.8 Animal-assisted therapy with dogs was found to decrease agitated behaviors and enhance socialization in patients with dementia.9-11 A preliminary study showed that interacting with a therapeutic robotic cat decreased agitation and increased pleasure and interest in nursing home residents with dementia.12 Although the effects of animal-assisted activities and therapy on agitated behaviors in the elderly are promising, the duration of beneficial effect, the relative benefits of dogs residing on a special care unit for patients with Alzheimer disease versus visiting the patients, and the confounding effects of animals on caregivers are unclear.9Preliminary studies suggest that tender touch, hand, and slow-stroke massage may help reduce agitation and improve well-being in older adults with dementia.4,13-16 Although limited, the available information is in favor of touch and massage therapy for behavioral disturbances in patients with dementia; however, definitive evidence about their benefits and adverse effects is lacking.17Simulated presence therapy is an individualized therapy that uses voice recordings to suggest the presence of meaningful persons and evoke associated positive emotional experiences in patients with memory loss. being able to get an erection, but not having it last long enough for sex. If after this, the patient is still experiencing BPSD, then the patient may need an increased dose of cholinesterase inhibitors or additional medications. ADEPT tool. Additionally, investigators in a clustered site study in Norwegian nursing homes [47] found that among 352 patients with moderate to severe dementia, verbal aggression, pacing, and restlessness responded to personalized pain therapy, using a combination of pregabalin, acetaminophen, buprenorphine patches, or extended-release morphine. Am J Geriatr Psychiatry. http://www.nivel.nl/pdf/Multi-Sensory-Stimulation-in-24-hour-dementia-care.pdf. Various studies have considered the use of complementary and alternative medicines to treat aggression, including cannabis, which is legal in some parts of the USA (although still illegal under federal statute). Papers of particular interest, published recently, have been highlighted as: National Library of Medicine Cummings JL, Geldmacher D, Farlow M, Sabbagh M, Christensen D, Betz P. High-dose donepezil (23 mg/day) for the treatment of moderate and severe Alzheimers disease: drug profile and clinical guidelines. Three systematic reviews, three randomized controlled trials, and two evidence based guidelines were identified regarding the treatment of older adults with insomnia, agitation, or delirium with benzodiazepines or other sedative hypnotic agents. 2002; (4):CD003152.30. Am J Recreation Ther. Our initial search generated 1448 potentially pertinent articles. Use of individualized music by trained staff and family: translating research into practice. Chronic divalproex sodium to attenuate agitation and clinical progression of Alzheimer disease, Valproate preparations for agitation in dementia. Additionally, those receiving aromatherapy started with higher agitation scores, thus had more potential change in behavior compared to the control group. Tampi RR, Tampi DJ, Balachandran S, Srinivasan S. Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses. Those with short half-lives and no active metabolites, such as lorazepam or oxazepam, are preferred.43In the light of limited evidence-based literature to support the use of psychotropic medications in the treatment of agitation, the decision about which medication to use should be determined largely by the patients unique needs and characteristics, the adverse-effect profile of the medication, and the benefit-to-risk ratio of treating versus not treating with a given medication.43ConclusionsAgitation in older adults is a complex syndrome associated with multiple psychiatric and medical conditions and comorbidities. Key Message. Add-on prolonged-release melatonin for cognitive function and sleep in mild to moderate Alzheimers disease: a 6-month, randomized, placebo-controlled, multicenter trial. As there is still no FDA-approved medication to treat agitation and aggression among older adults with dementia, future studies are needed to build the evidence base regarding real-world effectiveness and observed side effects of these commonly used medications. Before Household members of persons with Alzheimers disease: health conditions, healthcare resource use, and healthcare costs. Buspirone was evaluated in a retrospective observational study of BPSD, using an average dose of 25.7 mg 12.50mg [26].Among 179 patients, 68% had improved scores on the Clinical Global Impression scale, which assesses patient response to medication in relation to baseline severity of mental illness. A small study of 36 patients suggested that adding citalopram to a medication regimen may facilitate subsequent discontinuation of anti-psychotics for older adults with AD [38]. Of note, some patients experienced significant gastrointestinal upset with the increase in donepezil dose, but no other adverse events were noted [20]. Retrospective study on the benefits of combined memantine and cholinesterase inhibitor treatMent in AGEd patients affected with Alzheimers disease: the MEMAGE study. Anti-psychoticsespecially risperidone, aripiprazole, and olanzapinehave been evaluated in multiple studies and demonstrated improvement in severe agitation, aggression, and psychosis (e.g., delusions, hallucinations) among patients with AD [34]. Evidence-based practice recommendations for working with individuals with dementia: simulated presence therapy. However, patients receiving citalopram were more likely to experience QT prolongation and worsening of cognition at 30 mg/day dosing. Wade AG, Farmer M, Harari G, Fund N, Laudon M, Nir T, et al. Bethesda, MD 20894, Web Policies Review of safety and efficacy of sleep medicines in older adults, Pharmacotherapies for sleep disturbances in dementia. Cholinesterase inhibitors have a generally favorable safety profile and are generally well tolerated. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. In a small case series, gabapentin reduced aggression among seven patients with vascular dementia or mixed vascular/AD, using daily doses ranging from 200 to 600 mg daily. Martinon-Torres G, Fioravanti M, Grimley EJ. Most common adverse effects for cholinesterase inhibitors are nausea, vomiting, and diarrhea, which often subside after dose reduction as the side effect is dose related. Lithium treatment for agitation in Alzheimers disease (lit-AD): clinical rationale and study design, Allopurinol for the treatment of refractory aggression: a case series. Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, et al. Bohnen NI, Kaufer DI, Ivanco LS, Lopresti B, Koeppe RA, Davis JG, et al. Hicks-Moore SL. 1. Kyomen HH, Hennen J, Gottlieb GL, et al. West J Nurs Res. A different trial explored the utility of rivastigmine patches in conjunction with memantine to treat aggression in 147 patients with mild to moderate AD. Despite its impact on elderly patients, caregivers, and health care costs, there is much that is unclear about the causes, prevention, and treatment of agitation. Cochrane Database Syst Rev. Gerdner LA. van der Linde RM, Dening T, Stephan BC, Prina AM, Evans E, Brayne C. Longitudinal course of behavioural and psychological symptoms of dementia: systematic review. 2002;57: 461-468.34. Role of donepezil in the management of neuropsychiatric symptoms in Alzheimers disease and dementia with Lewy bodies. Memantine may be effective as an add-on therapy for BPSD. This retrospective open-label study may be prone to treatment selection bias. Seppala LJ, Wermelink A, de Vries M, Ploegmakers KJ, van de Glind EMM, Daams JG, et al. 2002;51:317-323.15. Introduction. Van Leeuwen E, Petrovic M, van Driel ML, De Sutter AI, Vander Stichele R, Declercq T, et al. Richeson NE, Neill DJ. It is intended to provide individualized, gentle sensory stimulation without the need for higher cognitive processes, such as memory or learning, in order to achieve or maintain a state of well-being.26,27When integrated as part of 24-hour care in nursing home residents with dementia, it was found to be effective in reducing agitated behaviors over an 18-month period.26,28 However, a session-based Snoezelen program did not show any effects on behavior disturbances during or just after the sessions or at a 1-month postintervention evaluation.29Validation therapy was developed for the elderly with cognitive impairments and is based on the concept of validation, the acceptance of the patients reality and personal experience. Roth DL, Stevens AB, Burgio LD, et al. Optimal Management of Psychosis & Agitation in the Elderly Psychosis and agitation in the elderly -- impact and prevalence, differential diagnosis, and strategies for management -- are explored in this program. 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