Psychiatric Emergencies in the Elderly

Keys to Diagnosis, Assessment, and Management

By Joanna Piechniczek-Buczek, MD | July 9, 2010

Dr Piechniczek-Buczek is chief of psychiatry at the Quincy Medical Center in Quincy, Mass, a clinical affiliate of Boston University School of Medicine. She has no conflicts of interest concerning the subject matter of this article.

Dementia

Dementia is a common neuropsychiatric syndrome associated with progressive decline in function across multiple cognitive domains. It affects 8% to 10% of people older than 65 years and nearly 50% of those older than 85 years.⁵⁴ Alzheimer disease is the most common cause of dementia (60%), followed by vascular dementia (20%), and dementia with Lewy bodies (15%).⁵⁵ About 80% of patients with dementia experience some form of behavioral or psychological symptoms of dementia (BPSD). These include agitation and aggression,delusions, hallucinations and misidentifications, screaming and repetitive vocalizations, circadian rhythm dysregulation, and wandering.

BPSD can cause significant distress for patients and their caregivers and is associated with poorer prognosis, rapid cognitive decline, diminished quality of life, and institutionalization.⁵⁶ Successful treatment of psychiatric and behavioral problems is associated with better outcomes, such as improved quality of life, decreased caregiver stress, and reduced patient suffering.⁵⁷

The first step in evaluating behavioral disturbance in a patient with dementia is to assess and explore medical, pharmacological, and environmental variables that may have precipitated the behavior. Table 9 presents possible factors that lead to behavioral escalation in patients with dementia.⁵⁸ It is essential to identify and correct all modifiable causes of behavioral distress; however, the evaluation can be challenging because of the fluctuating nature of the symptoms and the patient’s impeded ability to communicate. Validated and reliable scales, such as the Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) or the Cohen-Mansfield Agitation Inventory (CMAI) provide additional aid in evaluating and tracking behavioral changes in dementia patients.⁵⁹

The causes of BPSD are multifaceted and include neurobiological, psychological (premorbid coping styles), and social aspects. The neurobiology of behavioral manifestations involves a correlation between the decreasing cholinergic function, the depletion of serotonin and norepinephrine(Drug information on norepinephrine) levels in depressive and agitation symptoms, and the dysregulation of g-aminobutyric acid, serotonin, and norepinephrine in association with aggressiveness and impulsivity.⁶⁰

Care of patients with BPSD typically involves a wide range of psychosocial treatments with a focus on the patient’s physical health, safety of the environment, and psychiatric symptoms (Table 10). Behavioral complications that are primarily treated nonpharmacologically include circadian rhythm abnormalities, wandering, vocalizations, and catastrophic reactions (emotional response of various intensity to an overwhelming task or situation).⁶¹ Other symptoms such as psychosis, agitation, and aggression historically have been described as “medication-responsive.”

It is important to point out that there is no FDA-approved indication for a medication to treat these common and debilitating behavioral problems. Antipsychotic medications have been used off-label, but the FDA black-box warning that links these medications to increased mortality (most commonly from cardiac or infectious causes) and research findings that emphasize either modest medication efficacy or lack of it, significantly curtail prescribing practices.⁶²

In a 2008 American College of Neuropsychopharmacology white paper, a group of experts made several recommendations about treatment of agitation and psychosis in patients with dementia.⁶² Identification and correction of possible reversible causative factors along with environmental, interpersonal, social, and medical interventions should be considered first. Families, patients, and caregivers should be involved in the decision-making process, with a full appreciation of the benefits and shortfalls of currently available strategies.

Consider continuous pharmacological management only for patients with persistent and severe symptoms and provide ongoing monitoring of effectiveness. Use the lowest effective medication dosages for the shortest period necessary to stabilize symptoms in this population.⁶³

Pages: 1 2 3 4

Also in this Special Report

Enhancing Clinician Safety and Managing Psychiatric Emergencies

Safety in the Evaluation of Potentially Violent Patients

Managing a Psychiatric Emergency

Psychiatric Emergencies in the Elderly

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Psychiatric Emergencies in the Elderly

Keys to Diagnosis, Assessment, and Management

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