Management of Agitation, Confusion, and Distress in Elderly Patients with Dementia

Initial Assessment and Non-Pharmacological Approaches

• The American Geriatrics Society recommends performing a thorough assessment of potential causes for the patient's agitation, confusion, and distress, including evaluation for pain, discomfort, infections, dehydration, fecal impaction, and adverse medication effects 1, 2
• Assess for environmental, situational, social, and psychological factors that may be contributing to her distress, and implement an interdisciplinary approach involving the patient's family and retirement home staff to develop individualized care plans 1, 2
• Describe and quantify verbal, nonverbal, and physical behavioral symptoms to better understand patterns and triggers 1

Non-Pharmacological Interventions

• Provide meaningful activities tailored to the patient's past roles, interests, and current abilities, and increase social engagement through structured activities appropriate for her cognitive level 1, 4
• Improve communication techniques with the patient, using calmer tones and simpler single-step commands, and consider light touch to reassure and redirect 5
• Establish predictable daily routines that promote safety and well-being, and address loneliness and social isolation through appropriate social support programs 4, 5

Medication Management

• The American Geriatrics Society considers SSRIs like citalopram as first-line pharmacological treatments for agitation in dementia when medication is necessary, but recommends periodic attempts to taper or discontinue medication for dementia-related behavioral symptoms 1, 3

Ongoing Monitoring and Follow-up

• Regularly reassess the effectiveness of both non-pharmacological and pharmacological interventions, and evaluate for any new medical conditions or medication side effects that could be contributing to behavioral symptoms 1, 2

Caregiver Support and Education

• Educate the caregiver about the link between dementia and behavioral symptoms, and emphasize that behaviors are not intentional but manifestations of the disease 2, 5
• Provide strategies for effective communication and managing difficult situations, and connect the caregiver with support resources to manage caregiver stress 1, 5

Common Pitfalls to Avoid

• Avoid excessive reliance on medications without addressing underlying causes of distress, and do not dismiss the patient's expressions of wanting to leave as merely symptoms; they may indicate legitimate unmet needs 1, 3, 5
• Avoid confrontational approaches or complex explanations that may increase agitation, and do not overlook the importance of regular medication review and attempts at dose reduction 1, 5
• Avoid using physical restraints or unnecessary psychotropic medications to manage wandering behaviors 7, 8