Executive Summary – Mar. 21, 2016
Nonpharmacologic Interventions for Agitation and Aggression in Dementia
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Dementia and Agitation and Aggression
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) categorizes individuals with acquired cognitive deficits as having major or minor neurocognitive disorders (NCDs).1 Subtypes of NCDs include major and mild NCD due to Alzheimer's disease, frontotemporal disorder, or Lewy bodies, and vascular NCD. Historically, patients with these NCDs have been referred to as having dementia. Because "dementia" is the far more familiar term, we have used it rather than "NCD" throughout this report.
Many individuals with dementia exhibit neuropsychiatric symptoms at some point, usually in advanced disease stages.2 While neuropsychiatric symptoms are wide ranging, they tend to cluster into five domains: depression, agitation, aggression, apathy, and psychosis.3 Agitation and aggression are among the most challenging. Aggression is more serious than agitation because it can cause harm to the patient and others. Agitation/aggression in individuals with dementia is associated with institutionalization among community-dwelling people, social isolation, and other negative outcomes.4 These behaviors challenge formal and informal caregivers and contribute to caregiver anger, resentment toward the patient, stress, and decreased psychological health.5-7
Terminology about agitation/aggression is confusing.8 Agitation and aggression are typically grouped together as part of a spectrum, although they have different manifestations and implications. Agitation affects primarily the person with dementia (although the behaviors may be disruptive for others in his/her environment). By contrast, aggression involves at least one other person (the target of the aggression) and can represent real risks. Therefore, although it makes sense to identify and treat the underlying cause of agitation whenever possible, not all agitation needs intervention per se; sometimes, depending on its manifestation, agitation can simply be tolerated. Aggression, however, needs to be dealt with because of the possible risk to others. Despite these different treatment implications, agitation and aggression are frequently confounded in the literature. Hence, we refer to these symptoms as "agitation/aggression" for the remainder of this report.
Antipsychotic medications are often used to treat agitation/aggression in individuals with dementia. This was more common in the past but still occurs today despite current clinical guidance recommending nonpharmacologic interventions as the first choice for agitation/ aggression in dementia.9-12 Antipsychotic medications have limited efficacy and significantly increase the risk of stroke and mortality.13-15 For some individuals with dementia, side effects of antipsychotic medications can lower quality of life.16 Reducing unnecessary use of antipsychotics for behavioral symptoms in individuals with dementia is important. Evidence of effective nonpharmacologic approaches would strengthen the efforts to urge less use of inappropriate psychoactive drugs, but the absence of that evidence should not diminish such efforts in light of the harmful effects of these medications. By contrast, the nonpharmacologic approaches have virtually no reports of adverse effects.
Nonpharmacologic interventions aim to (1) prevent agitation/aggression, (2) respond to episodes of agitated and aggressive behaviors to reduce their severity and duration, and/or (3) reduce caregiver distress. Individuals with dementia typically reside in nursing homes or assisted living facilities or at home in their community (community dwelling). The duration of successful interventions varies with the goal of the intervention. Some are short lasting, designed to neutralize episodes of agitation/aggression when they occur. By contrast, preventive approaches aim to reduce the frequency and severity of agitation/aggression over time.
Interventions delivered in nursing homes and assisted living facilities can be at the patient level, where a therapy is delivered directly to the patient, or the care delivery level, involving the approach, staff, and/or environment used in care delivery. Strategies often involve specific activities or enhancing communication.17Care delivery–level interventions include a variety of care delivery models, staff/caregiver education and training, and environmental approaches.18 Examples include training to enhance staff knowledge and skills in managing behavioral symptoms among residents, care delivery models such as dementia care mapping, and enhancements to the environment aimed at reducing exposure to elements that induce agitation/aggression.
Interventions delivered to community-dwelling individuals with dementia can be at the patient or caregiver level. The caregiver is typically an informal family caregiver (i.e., an unpaid family member who provides care to the person with dementia). Patient-level interventions are similar to those in residential settings. Some patient-level interventions targeted to individuals in less advanced stages of dementia include activities, such as exercise classes. Caregiver-level interventions to address agitation/aggression typically provide education and skills training to enhance understanding of the disease process, specific symptoms, and how to best address agitation/aggression. Table A provides a classification scheme and examples of the types of interventions used in various settings.
Desired outcomes of nonpharmacologic interventions include a reduction in the incidence and severity of agitation and aggression. Measuring these outcomes is complex. A wide variety of instruments are available. Available instruments are (1) based on different theoretical frameworks, (2) designed to evaluate behaviors in different settings (e.g., home or nursing home), (3) intended to be administered by different individuals (e.g., caregiver, nurse, or patient), and (4) rely on a variety of mechanisms to obtain responses (e.g., interviews with people with dementia or direct observation). More than 45 specific instruments are used to evaluate behavioral symptoms in dementia. The appropriate instrument depends on disease severity and context of care (e.g., setting, severity of disease, and whether the purpose is to identify any agitation/aggression or specific behaviors).3 Instruments that specifically measure agitation/aggression include the Agitated Behavior in Dementia Scale (ABID),19 the Cohen-Mansfield Agitation Inventory (CMAI),20 and the Pittsburgh Agitation Scale (PAS).21 Additionally, some general behavioral symptom instruments include subscales specific to agitation/aggression.
Evidence synthesis on the efficacy and comparative effectiveness of nonpharmacologic interventions for addressing agitated and aggressive behaviors in people with dementia is needed. This evidence could inform decisionmakers about the best ways to reduce the frequency and severity of those behaviors. Actions inspired by the evidence synthesis could improve functioning, reduce distress, and reduce or delay nursing home admission for individuals with dementia while reducing the use of antipsychotic drugs.
- EPC Project
- Nonpharmacologic Interventions for Agitation and Aggression in Dementia
- Research Review Mar. 21, 2016
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