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Agitation in Dementia
While memory impairment is often what comes to mind when one thinks of Dementia, agitation is what most often causes my phone to ring with a request for an evaluation. Behavioral changes, paranoid delusions, hallucinations and long periods of screaming were described by the psychiatrist Alois Alzheimer, for whom Alzheimer’s Disease is named, in 1907 in his original case description of the disease nearly 100 years ago. ‘Agitation’ is a term that is most often used to describe a wide variety of behavioral symptoms seen in patients with dementia. The medical term used to describe these symptoms is the Behavioral and Psychiatric Symptoms of Dementia, or BPSD for short.
It is estimated that BPSD affects up to 90% of all individuals with dementia over the course of their illness, and is independently associated with poor outcomes, including distress among patients and caregivers, long-term hospitalization, misuse of medication, and increased health care costs.
There are several categories of BPSD, these include:
- Disturbances of emotional experience such as mood lability, depression, anxiety, irritability/hostility, apathy, and crying spells.
- Psychotic experiences including delusions, hallucinations, and paranoia.
- Sleep Disturbances such as sleeping excessively, waking up frequently, sleepwalking and its related conditions.
- Appetite Disturbance can manifest as low to non-existent appetite and weight loss, excessive appetite/demands for food, and ingestion of non-edible substances.
- Disinhibited Behaviors include wandering (present in about 25% of patients with Alzheimer’s), yelling (seen is 25% of Nursing Home residents), excessive talking, inappropriate sexual behaviors, and hypermetamorphosis (the need to touch, and sometimes hoard, every object in sight).
- Personality changes can manifest both as acting in atypical ways as well as experiencing a ‘distillation’ of the personality so that the person behaves as a caricature of themselves.
- Uncooperative behaviors are most often related to personal care such as bathing, dressing, taking medications, and grooming activities.
- Certain behaviors can be more commonly associated with different types of Dementia. For example, hallucinations can be a prominent feature of Lewy-Body Dementia, and Complex Sleep Related Behavioral Disorder is often associated with Parkinson’s Dementia, and changes in personality can be the first symptoms of Fronto-Temporal Dementia.
While these behaviors are often manifestations of the underlying brain damage caused by dementia, they are sometimes related to co-occurring medical conditions which should be evaluated as part of an assessment of BPSD. These include things such as urinary tract infections, vitamin deficiencies, thyroid abnormalities, diabetes, kidney and liver function, and pain syndromes.
Assessment of BPSD begins with a thorough evaluation consisting of gathering information from multiple sources to learn not only about the onset and evolution of the BPAD and underlying dementia, but also a detailed assessment of medical conditions, all medications being taken by the individual, as well as an assessment of the possible contributors/triggers of the BPSD from the living environment.
Improvement of BPSD is often achieved through a combination of adjustments in medication, treatment of any underlying medical conditions, and modification of the individual’s environment/caregiver approach. Because there are so many different types of agitation and because each patient’s background, life story, medical issues, and temperament are unique, an individualized approach that takes all of these variables into account is most likely to be successful.