Disruptive agitated behavior is common in demented patients and is often diEcult to manage.' Although neuroleptic medications are frequently administered to agitated patients, these agents only help in about one-third of cases, and their utility is limited by serious side effects.' A specific cause of agitated behavior in a demented patient is often not identified, and the behavior may sometimes be related to pain or discomfort from an unrecognized medical problem. In this report, we describe a demented woman whose agitated behavior was greatly reduced following treatment of her cervical dystonia with botulinum toxin A.Case report. A 49-year-old demented woman was hospitalized for management of progressively worsening irritability, combativeness, and crying episodes of 6 months' duration. She had been healthy until 5 years earlier, when she began to experience progressive memory loss and inability to function a t her job.Initial evaluations for treatable dementias had been nondiagnostic, and a right frontal lobe brain biopsy performed 3 years into her course revealed Alzheimer's disease and cortical Lewy bodies. The course of her dementia included global cognitive decline, cogwheel rigidity (antedating the use of neuroleptic medication), and one generalized convulsion.At the time of this hospitalization, she was receiving phenytoin and chlorpromazine. On examination, she was uncooperative and agitated. She could not answer simple questions and would frequently whine or cry. There was prominent cogwheel rigidity a n d cervical dystonia. Folstein's Mini-Mental S t a t e Examination score was zero. Her score on the short-form CohenMansfield Agitation Inventory3 (CMAI) was 54, indicating a severe degree of agitation. There was no clinical evidence of systemic infection, fecal impaction, decubitus ulcer, or fracture. Screening laboratory data revealed normal SMA 18, CBC, and urinalysis. Phenytoin level was 12.6 mcg/ml.In an attempt to alleviate her agitated behavior, risperidone was substituted for chlorpromazine, but after 1 week her condition had not changed. Divalproex sodium (in doses sufficient to produce a serum level of 68 mgA) was then substituted for phenytoin, but her agitated behavior did not improve during 10 days of this treatment. The patient was then referred for botulinum toxin injections in an effort to relieve her prominent leftward Iaterocollis. A total of 145 U of botulinum toxin A was injected into her hypertrophied left sternocleidomastoid, left scalenus, left splenius capitis, and left trapezius muscles. Analgesic t r e a t m e n t w i t h propoxyphene napsylate a n d acetaminophen was also given.Over the next few days, her dystonic cervical muscles relaxed considerably, and her agitated behavior significantly decreased. Her crying episodes stopped, her appetite improved, she became much less irritable, and she began making regular attempts at verbal communication. Her post-treatment CMAI score was 30, with marked improvement on items assessing repetitive actions, repetitive verbalizations, kick...
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