Lin LW, Weng SC, Wu HS, Tsai LJ, Lin YL, Yeh SH. Some concerns have been raised on this approach's feasibility in patients who do not have offspring (79). Although risperidone revealed efficacy earlier, the drug produced a higher burden of side effects (110). O'Brien JT, Holmes C, Jones M, Jones R, Livingston G, McKeith I, et al.. Clinical practice with anti-dementia drugs: a revised (third) consensus statement from the British association for psychopharmacology, Frontotemporal dementia: therapeutic interventions. Dementia Treatment: An Unmet Need - Psychiatric Times Funding. Three previous RCTs showed comparable clinical efficacy of atypical antipsychotics and haloperidol (137, 139, 140). Ravina B, Putt M, Siderowf A, Farrar JT, Gillespie M, Crawley A, et al.. Donepezil for dementia in Parkinson's disease: a randomised, double blind, placebo controlled, crossover study. Regarding pimavanserin, recent phase II RCTs suggested efficacy in AD patients, although the safety profile needs further investigations. In this perspective, we can easily understand why RCTs have a hard time in disentangling VaD from AD (the most common cause of neurodegenerative dementia). The compound is FDA-approved for treating schizophrenia and major depressive disorder as add-on therapy (217). Catic AG, Mattison MLP, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues, Immersive virtual reality and persons with dementia: a literature review. FOIA The authors indicated that antipsychotic drugs have the highest efficacy for treating behavioral and psychotic symptoms. However, no RCTs have addressed the treatment of COVID-19-related agitation (207). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. Psychotropic drugs and renal failure: translating the evidence for clinical practice, Delirium in elderly adults: diagnosis, prevention and treatment. Treatment of behavioral and psychological symptoms of dementias with psychopharmaceuticals: a review. Baghdady NT, Banik S, Swartz SA, McIntyre RS. The first clinical study, a phase II, randomized, multicenter, double-blind, placebo-controlled trial ({"type":"clinical-trial","attrs":{"text":"NCT01584440","term_id":"NCT01584440"}}NCT01584440), evaluated the efficacy of AVP-923 (dextromethorphan/quinidine) at doses ranging from 20/10 mg once daily to 30/10 mg twice daily for 10 weeks (130). A self-guided Internet-based intervention for individuals with chronic pain and depressive symptoms: study protocol of a randomized controlled trial. Nevertheless, clinicians often liberally implement drugs used in other forms of dementia, even in the absence of evidence-based support. No use, distribution or reproduction is permitted which does not comply with these terms. Some meta-analyses also revealed clinical benefits on agitation using SSRIs, especially citalopram and sertraline (175). Careers. Delli Pizzi S, Franciotti R, Tartaro A, Caulo M, Thomas A, Onofrj M, et al.. shown to reduce agitation intensity and need for physical restraints [25] We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. 1 Agitation is one of the most common manifestations of mental health and behavioral disorders, dementia, and intoxication and withdrawal syndromes. 1 Agitation and aggression can disrupt care, cause injury, or necessitate use of physical restraint. Step 1: Assess situation and cause of agitation Delirium (make sure underlying medical cause is being addressed) Intoxication (central nervous system [CNS] stimulant vs. depressant) Primary psychiatric disorder (e.g., psychosis, mania) Undetermined cause Step 2: Attempt to de-escalate and utilize non-pharmacological interventions After the first cases of the novel coronavirus disease 2019 (COVID-19) were reported in Wuhan, China, in December 2019, the spread of SARS-CoV-2 rapidly became a pandemic, involving millions of patients worldwide. Older people are particularly susceptible to drug side effects, as co-existing metabolic disturbances can affect drug pharmacokinetics (40). When there are no absolute contraindications to any particular medication class, possible management includes administering alpha-2 agonists and low-potency antipsychotics, whereas BDZs should be avoided given their depressive effects on ventilation. FOIA For instance, the Dementia Care Mapping (DCM) (69, 72, 73), which is based on patients' systematic observations, has generated conflicting results. Nevertheless, some anecdotal evidence has indicated the efficacy and safety of atypical neuroleptics. This study was funded by the Alzheimer's Association Part the Cloud: Translational Research Funding for Alzheimer's Disease (PTC) PTC-19-602325 and the Alzheimer's AssociationGAAIN Exploration to Evaluate Novel Alzheimer's Queries (GEENA-Q-19-596282) (SLS). Furthermore, sertraline was demonstrated to decrease agitation or aggressiveness and other psychiatric symptoms, in a double-blind, randomized, placebo-controlled study (111). Mller MB, Terpolilli NA, Schwarzmaier SM, Briegel J, Huge V. Front Neurol. What's the best way to manage agitation related to dementia? Introduction: Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. Pharmacologic strategies should be used in concert with non-pharmacologic de-escalation efforts continuing during and after medication administration SEE OPPOSITE PAGE FOR MEDICATION DOSING The .gov means its official. Mild behavioral impairment and risk of dementia: a prospective cohort study of 358 patients. Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Lastly, ongoing studies are proposing virtual reality-related approaches that include music, sensory, and mental stimulations to improve cognitive functions (attention, executive function, visual and verbal memory) and psychological domains (agitation, depression, anxiety, and apathy) (8789). Surr CA, Holloway I, Walwyn REA, Griffiths AW, Meads D, Martin A, et al.. Rokstad AMM, Rsvik J, Kirkevold , Selbaek G, Saltyte Benth J, Engedal K. The effect of person-centred dementia care to prevent agitation and other neuropsychiatric symptoms and enhance quality of life in nursing home patients: a 10-month randomized controlled trial. 2023 May 31;19(2):185-194. doi: 10.13004/kjnt.2023.19.e19. Background Information Behavioural and Psychological Symptoms of Dementia (BPSD) EDs are the portal of access to the healthcare system for most patients with acute agitation and acute behavioral or mental health disorders. Korean J Neurotrauma. eCollection 2023. Cognitively impaired patients with history of seizures or chronic pain can also be treated with antiepileptic drugs in case of mild delirium (135). TIPSHEET: AGITATION TREATMENT APPROACHES Definition: Agitation is defined as "excessive verbal and/or motor behavior" that can be loud, disruptive, hostile, sarcastic, threatening, hyperactive, and/or combative Keep these points in mind D'Cunha NM, Nguyen D, Naumovski N, McKune AJ, Kellett J, Georgousopoulou EN, et al.. A mini-review of virtual reality-based interventions to promote well-being for people living with dementia and mild cognitive impairment, Use and impact of virtual reality simulation in dementia care education: a scoping review. Finally, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be a precipitating factor for agitation because of the related long-term hospitalization and quarantine (4244) or the ensuing viral encephalitis, critical illness encephalopathy, and systemic inflammation (45). Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation) - Roppolo - 2020 - Journal of the American College of Emergency Physicians Open - Wiley Online Library Skip to Article Content The FDA recommends a maximum daily dose of citalopram of 20 mg/day in patients above the age of 60 (157). PDF PED Agitation Pathway - UNC School of Medicine Thus, careful reduction or redistribution of dopaminergic drugs should represent the first option for these patients. However, it is safe to say that pharmacological treatments should be implemented as a second choice, whereas non-pharmacological interventions should be person-centered, preferred, and prioritized. Line Treatment 3. rd. Even if AChEIs seem to have positive effects on other behavioral symptoms (such as depression and anxiety) (142), they did not show good efficacy in the treatment of agitation in AD (160162). Person-centered care (PCC) is an operating system in healthcare, which considers the health practitioner and the patients as partners in achieving tailored care that meets patients' needs in a unique way (67, 68). Regarding the use of antiepileptic drugs, two studies tested gabapentin for acute onset of agitation, but not a large and robust body of evidence is available to suggest its use in FTD patients (198). Anderson MS, Homdee N, Bankole A, Alam R, Mitchell B, Hayes J, et al.. Behavioral interventions for alzheimer's management using technology: home-based monitoring. government site. However, in line with the recent concerns about an increased risk of death in elderly patients treated with antipsychotic drugs (both atypical and conventional) (186), clozapine and quetiapine should be cautiously employed as a first-line treatment for agitation. There were not significant side effects and cognitive deterioration, Memantine did not show its effectiveness compared with placebo, Placebo-controlled trial Comparison with antipsychotics, Efficacy of memantine compared with antipsychotics Second endpoints: improvement in NPI, MMSE, and mortality, No benefits for memantine in the long-term treatment and prophylaxis, Institutionalized patients with AD or VaD, Quetiapine was well-tolerated and did not worsen parkinsonism, Rivastigmine 612 mg daily produced statistically and clinically significant behavioral effects, Rivastigmine was associated with moderate improvements in agitation but also with higher rates of nausea, vomiting, and tremor, Donepezil improved cognition and seemed to be well-tolerated and not to worsen parkinsonism, Beneficial effects on memory and improvement of other cognitive deficits, Donepezil was well-tolerated and did not worsen PD. 17 Dosing for delirium tends to be . The involvement of frontal lobe dysfunction in the occurrence of agitation has been also confirmed by functional imaging studies in both cognitively unimpaired subjects (20, 21) and AD patients (22). official website and that any information you provide is encrypted NPS are common in the prodromal stage of dementia and can precede the onset of cognitive impairment. The agitation associated with neurodegenerative diseases can occur at any disease stage and takes a significant toll on patients and caregivers. Regardless of the treatment setting, identifying the agitated patient early is a necessary skill. Progresses in treating agitation: a major clinical challenge in Alzheimer's disease. eCollection 2023 Jun. Sampson EL, Raven PR, Ndhlovu PN, Vallance A, Garlick N, Watts J, et al.. A randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement, Donepezil for anticholinergic drug intoxication: a case report. Reus VI, Fochtmann LJ, Eyler AE, Hilty DM, Horvitz-Lennon M, Jibson MD, et al.. Lauretani F, Bellelli G, Pel G, Morganti S, Tagliaferri S, Maggio M. Treatment of delirium in older persons: what we should not do! Lebert F, Stekke W, Hasenbroekx C, Pasquier F. Frontotemporal dementia: a randomised, controlled trial with trazodone. Three placebo-controlled studies on donepezil in PDD patients (120122) produced no effects vs. placebo for psychiatric disturbances. These drugs reduced agitation, anxiety, and impulsiveness and worsened apathy and cognitive functioning (191193). Current managing guidelines for dementia-related agitation recommend implementing non-pharmacological approaches as the first line of intervention (32), whereas considerable research now focuses on prevention strategies. Indeed, a strict correlation among neuropsychiatric symptoms (NPS), especially aggressiveness, and tau pathology, rather than amyloid, is commonly reported in AD patients (12, 14, 15).