Non-pharmacological management of agitation in dementia

Kathy Fletcher RN DNP GNP-BC FAANDirector Geriatric Nursing Programs Riverside Health

SystemClinical Assistant Professor of Nursing University of

Virginia

Objectives

• Discuss the prevalence of neuropsychiatric symptoms in residents with dementia

• Identify the negative outcomes associated with agitation in residents with dementia

• Describe the various nonpharmacological therapies used to address agitated behaviors

• Review the literature on the effectiveness of non-pharmacological therapies to help manage agitation in residents with dementia

Prevalence of Neuropsychiatric Symptoms (NPS)in individuals with dementia

• 40% of residents with dementia in special care units and nursing homes have severe to very severe cognitive impairment (Gruneir, 2007)

• The majority of residents with severe dementia (50-80%) have one or more NPS—the most common agitation, aggression, psychosis, depression, apathy, withdrawal & aberrant motor behavior (Zuidema, 2007; Kverno, 2008)

Negative outcomes of agitation in residents with dementia

• Often it is a reason for LTC admission in the first place

• Increased use of psychotropic drugs • Diminished quality of life• Resident/family distress• Caregiver burden

Best Person-Centered Practice • First determine if the behavior is harmful to the

resident or to others• Second: ABC’s: Antecedents, Behavior,

Consequences• Third determine if the behavioral or psychological

symptoms are the consequence of a physical illness or medications used to treat these

• Fourth try non-pharmacological approaches• Last use drugs in the lowest possible dose for the

shortest period of time

Non-pharmacological therapies

Standard therapies:

BehavioralReality orientationValidationReminiscence

Non-pharmacological therapies

Alternative /complementary therapies:ArtMusicActivityComplementaryAromaBright-lightMultisensory approachesEmotion oriented

Non-pharmacological therapies

Psychotherapies :

Cognitive-behavioralInterpersonal

Summary

• Person-centered and tailored interventions are most appropriate with non-pharmacological approaches

• The need to work with professionals, families, and the system to address this concern

• Education of the staff to change attitudes and behaviors in intervening with residents demonstrating NPS

• More high level research in this area is needed

References: • Kverno, KS et al (2009). Research on treating neuropsychiatric symptoms

of advanced dementia with nonpharmacological strategies, 1998-2008: a systematic literature review. International Psychogeriatrics, 21 5:825-843.

• Douglas, S et al (2004). Nonpharmacological interventions in dementia. Advances in Psychiatric Treatment, 10, 171-179.

• Cohen-Mansfield, J et al (2007). Nonpharmacological treatment of agitation: a controlled trial of systematic individualized intervention. Journal of Gerontology, 62A, #8, 908-916.

• Kong, EH et al (2009) Nonpharmacological intervention for agitation in dementia: a systematic review and meta-analysis. Aging and mental health, 13, #4, 512-520.

• Ayalon, L et al (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166, 2182-2188.