Reduction and prevention of agitation in persons with neurocognitive disorders: an international psychogeriatric association consensus algorithm

Abstract

Objectives To develop an agitation reduction and prevention algorithm is intended to guide implementation of the definition of agitation developed by the International Psychogeriatric Association (IPA) Design: Review of literature on treatment guidelines and recommended algorithms; algorithm development through reiterative integration of research information and expert opinion Setting: IPA Agitation Workgroup Participants: IPA panel of international experts on agitation Intervention: Integration of available information into a comprehensive algorithm Measurements: None Results The IPA Agitation Work Group recommends the Investigate, Plan, and Act (IPA) approach to agitation reduction and prevention. A thorough investigation of the behavior is followed by planning and acting with an emphasis on shared decision-making; the success of the plan is evaluated and adjusted as needed. The process is repeated until agitation is reduced to an acceptable level and prevention of recurrence is optimized. Psychosocial interventions are part of every plan and are continued throughout the process. Pharmacologic interventions are organized into panels of choices for nocturnal/circadian agitation; mild-moderate agitation or agitation with prominent mood features; moderate-severe agitation; and severe agitation with threatened harm to the patient or others. Therapeutic alternatives are presented for each panel. The occurrence of agitation in a variety of venues—home, nursing home, emergency department, hospice—and adjustments to the therapeutic approach are presented. Conclusions The IPA definition of agitation is operationalized into an agitation management algorithm that emphasizes the integration of psychosocial and pharmacologic interventions, reiterative assessment of response to treatment, adjustment of therapeutic approaches to reflect the clinical situation, and shared decision-making.

Behavioral or neuropsychiatric symptoms of Alzheimer's disease: from psychopathology to pharmacological management

“…Agitation is a very troublesome behavioral problem in AD with major impacts, including costs and caregiver burden. 62,63 In a community-dwelling study involving older adults with a range of cognitive impairments, the prevalence of agitation ranged from 8.3% to 48.9%. 64 Agitation increases with dementia severity, and even higher rates (> 50%) are observed in nursing homes.…”

“…Dopamine-blocking agents can cause akathisia, a condition characterized by subjective and objective restlessness and typically seen in patients taking antipsychotics. 68 For nighttime disruptive behaviors, trazodone and orexin receptor antagonists (e.g., suvorexant, lemborexant) have been used [63]. Of note, a recent double-blind, placebocontrolled study (SYMBAD) found no effect of mirtazapine an atypical antidepressant with sedative properties at lower doses but activating in higheron AD-related agitation and potentially increased mortality associated with its use.…”

“…Recently, the International Psychogeriatrics (IPA) Agitation Work Group proposed an algorithm for managing agitation in neurocognitive disorders. 63 Using the ‘Investigate, Plan, and Act’ (also IPA) approach, in which the investigation of potential causative or contributor factors is followed by planning and acting, with reiterations of the process until agitation is controlled, the Working Group emphasized the integration of psychosocial and pharmacologic interventions. Psychosocial interventions that have multiple components target the caregiver (e.g., communication skills, education, self-care) and the patient (e.g., person-centered, aerobic activities, music, massage) and are delivered with regular follow-up have more therapeutic benefit.…”

Effects of reminiscence therapy on cognition, agitation, and quality of life in older adults with dementia receiving long‐term care

“…These interventions may include medication and nonpharmacological therapy. [8][9][10] Reminiscence therapy (RT) is one of the psychosocial approaches in which memories are used to protect and improve the mental health of older adults, improve their quality of life, and ensure the adaptation of older adults to the ageing process. 11 People's memories of the past help them maintain continuity in their internal psychological characteristics, social behaviour, and social conditions in the face of change.…”

“…However, several interventions can help manage the symptoms. These interventions may include medication and nonpharmacological therapy 8–10 …”