The Treatment of Agitation
Eileen P. Sloan, PhD, MD
Resident in Psychiatry,
Department of Psychiatry,
University of Toronto.
Introduction
Agitation is an aspect of dementia that can have serious emotional, medical and health-care system consequences. It results in decreased quality of life for both patient and caregiver and is often cited as the reason for the patient being admitted to a long-term care facility. Within the nursing home setting, agitation may often result in increased use of physical and/or chemical restraints, with concomitant problems such as physical injury and falls. Medical care of the agitated patient can be compromised and nursing staff is required to spend greater amounts of time caring for the agitated patient.
Definition and Prevalence
Allen (1999) points out that "agitation" is not a diagnosis but refers to a constellation of symptoms.1 Cohen-Mansfield and Billing (1986)2 define agitation as "inappropriate verbal, vocal or motor activity unexplained by apparent needs or confusion." These authors divide the symptoms of agitation into three: aggressive behaviours (hitting, kicking, verbal aggression, spitting); inappropriate physically non-aggressive behaviours (pacing, repetitious mannerisms, robing and disrobing); and inappropriate verbal agitated behaviours (screaming, complaining, constant demands for attention).3 Clustering of symptoms has important implications for treatment, since, as discussed below, different aspects of agitation may respond to different interventions.
The prevalence of agitation in dementia is unclear, which may result from the lack of an internationally agreed upon definition. Cohen-Mansfield (1986) found that 93% of patients in a nursing home had one or more symptoms of agitation at least once a week. Others report a similar figure4 although prevalence rates as low as 36% have been reported.5
Etiology
Agitation in dementia is multifactorial in etiology, with factors ranging from the patient's neuroanatomical structure to his or her environment playing a role.
Anatomical areas involved in the control of behaviours in the normal brain, such as the amygdala, hippocampus, hypothalamus and septal nuclei, along with areas in the neocortex, may be affected by dementia, both anatomically and in terms of faulty neurotransmitter systems that serve these areas.6 For example, disturbance of the serotonergic system is implicated in aggression in animals and humans and it is hypothesized that impairment in this system may result in agitated behaviours in patients with dementia.7,8
Also implicated in these patients are decreased levels of acetylcholine. Depletion of acetylcholine in the brains of patients with Alzheimer's disease is well documented and this has been shown to correlate not only with memory, but with behavioural disturbance.9 Acetylcholinesterase inhibitors, such as tacrine and physostigmine, have been shown to reduce agitated behaviour in AD patients.10
Further research is needed to determine if other neurotransmitter systems may also be involved in the development of agitation.
Medical illness can be overlooked as an etiological factor in the development of agitation since patients who are agitated tend to receive less medical care. General medical conditions, such as infection (urinary tract infection and pneumonia are common culprits), constipation, side-effects of medications or interactions between medications, pain, cerebrovascular disease or cardiac problems, can all contribute to agitation. Delirium must be ruled out as a cause of the agitated behaviour. Disruption of sleep and circadian rhythms, common in patients with dementia, may also play a significant role.
The importance of environmental factors cannot be overstated. Isolation and loneliness can be problematic as can overcrowding and overstimulation. Mealtimes can trigger agitation because of physical discomfort (hunger), increased noise and activity, and increased proximity to co-residents.1 The physical aspects of the environment, such as rooms and corridors that look alike, may contribute to confusion and disorientation. Changes in the environment, either in routine or in