Agitation, dementia and intervention possibilities

The occurrence of behavioural disorders is common in people with dementia, increasing as the disease itself progresses. The presence of these neuropsychiatric symptoms is the main cause of institutionalization and increased hospital stays, worsening the quality of life of both patients and their caregivers.

The range of behavioural disorders is very wide, and they can be grouped into different clusters (of the anxiety-depressive type, psychotic, agitation/aggressiveness, mania, apathy) in order to describe them adequately and to set out different intervention objectives. It is also important to know the frequency and intensity of these clusters and the consequences they generate for the patient and their carers.

Pharmacological interventions involve a series of risks in terms of cognitive worsening, gait and balance disorders, increasing cardiovascular mortality, with a small degree of effectiveness, and therefore require an exhaustive monitoring of the benefit/risk balance.

In a systematic review* published in the British journal of psychiatry, the different non-pharmacological interventions in the management of agitation in institutionalised patients with dementia are evaluated, where it is shown that training in communication skills and observation of caregivers, as well as structured music therapy, sensory intervention (mainly tactile) decrease agitation, some even 3-6 months after its implementation. However, other activities such as aromatherapy or light therapy do not demonstrate their effectiveness.

It is curious that the training and education of relatives does not change the agitation of patients to any great extent, so it is difficult to extend the conclusions of the study to the community environment. The clinical trials included in the review present great heterogeneity in terms of scales used, types of intervention, comorbidities and medications of the participants studied.

The most relevant aspect of this study, as the authors state, is the assessment of undetected needs in patients with dementia (pain, constipation, hunger, thirst, sensory deprivation, side effects of medication...), seeking maximum comfort as the main objective and focusing activities on the person's well-being and not so much on activities related to the care structure. After an adequate definition of the psychological or behavioural problem and ruling out possible related causes, the effectiveness of the measures implemented must be monitored and supervised. The knowledge obtained from the different reviews should be used to implement those measures that demonstrate their effectiveness, as well as continuous training of the formal carers.

* Gill Livingston, Lynsey Kelly, Elanor Lewis-Holmes et al. Non-pharmacological interventions for agitation in dementia: systematic review of randomized controlled trials. The British Journal of Psychiatry (2014);205, 436–442.