Agitation in older adults is frequently associated with multiple psychiatric and medical conditions and comorbidities. It commonly occurs in patients with anxiety, affective illness, psychosis, dementia, stroke, brain injury, delirium, or pain, and in those who misuse psychoactive medications or other substances. Optimal treatment strategies to reduce or prevent agitation in older adults encompass a multidisciplinary model that used nonpharmacological and pharmacological/somatic approaches. In this article, we discuss clinical approaches for evaluating and managing agitation in older adults.
Defining and determining the causes of agitation
To focus treatments appropriately, it is important to specifically define the target signs or symptoms that are being labeled as “agitation.” Agitation is a nonspecific concept that broadly encompasses various activity disturbances such as those delineated in Table 1.
Specifying the actual behavior is especially important so that all treatment team members can be consistent in their understanding and subsequent approach to and treatment of the patient. For example, it is difficult to devise an effective treatment plan for agitation if some staff members refer to a patient’s combativeness as agitation, and other staff members use the term agitation to describe the same patient’s hypersexual behaviors. If each type of agitation is defined, a focused plan to manage, monitor, and evaluate the progress of each unique behavior can be developed.
Once the behavioral target signs and symptoms are identified, the next step is to determine their causes in order to formulate appropriate multidisciplinary interventions. A clinically relevant way to categorize causes is to first identify the circumstances antecedent to the behavioral target signs and symptoms that trigger the agitation and then to identify the illnesses or pathological conditions that exacerbate the agitation.
Nonpharmacological interventions are often effective for managing agitated behaviors that stem from such antecedent triggers. The solution is to develop an appropriately stimulating environment, remove or limit exposure to noxious stimuli, and provide the patient with basic nutritional and personal needs. Table 2 describes the circumstances that may trigger agitation.
Various nonpharmacological therapies have been developed to provide patients with appropriately stimulating environments and to help redirect the patient and manage the setting to minimize events that can trigger agitation. These include music therapy, animal-assisted activities and therapy, touch/massage therapy, simulated presence therapy, light therapy, multisensory stimulation, validation group therapy, and skills training and behavioral-milieu management.
Psychiatric disorders (such as anxiety, mania, depression, psychosis, and dementia) and somatic conditions (such as stroke, brain injury, delirium, pain, discomfort, and adverse effects of medications) have all been implicated in exacerbating agitation. Common disorders, separately or in combination, that may co-occur with psychiatric conditions and cause acute pain and discomfort, and may contribute to delirium, are listed in Table 3. These conditions are more likely to contribute to agitated behaviors in patients with underlying dementia, partly because such persons have an impaired ability to obtain help for pain or discomfort through coherent conversation.
Common disorders (eg, arthritis, hearing loss) are often overlooked because of their chronic nature or because of difficulties in the patient evaluation (eg, difficulty of obtaining a clean-catch urine specimen for cultures and sensitivities from a resistant patient). Iatrogenic causes, such as diuretics given at bedtime rather than early in the day, a rebound effect from a sedative or hypnotic dose reduction or discontinuation, and paradoxical disinhibiting reactions from benzodiazepine use can also exacerbate agitation.
Thorough evaluation of the patient’s physical condition is essential so that agitation exacerbated by such disorders is not mistakenly attributed entirely to psychiatric illness and treated primarily with psychotropic medication. Table 4 presents some psychiatric conditions that may contribute to agitation.
Dr Kyomen is associate psychiatrist in the department of psychiatry at Mclean Hospital in Belmont, Mass, and clinical instructor in the department of psychiatry at Massachusetts General Hospital, Boston. Dr Whitfield is a biostatician in the department of psychiatry at Massachusetts General Hospital.
Dr Kyomen reports that she is a consultant for AstraZeneca Pharmaceuticals LP, Bayer Corporation, Bristol-Meyers Squibb, Merck, Eli Lilly, Roche, GlaxoSmithKline, Novartis, UCB Pharma, Wyeth-Ayerst Laboratories, and Pfizer Inc. She has received grant/research support from Bayer Corporation, Bristol-Myers Squibb, Eli Lilly, Roche, UCB Pharma, Wyeth-Ayerst, Pfizer, Inc, NIH, the John A. Hartford Foundation, the National Institute on Aging, and the Veterans Administration.
Dr Whitfield reports that he has no conflicts of interest concerning the subject matter of this article.
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