Addressing Agitation in Dementia

With 7 million individuals living with Alzheimer disease and dementia in the United States, effective home-based strategies are crucial to prevent institutionalization

Psych Congress Network Section Editor Leslie Citrome, MD, MPH, clinical professor of psychiatry, New York Medical College, Valhalla, New York, addresses the pressing issue of managing agitation in Alzheimer disease, the topic of his Friday session at the 2023 NEI Congress in Colorado Springs.

In this video, Dr Citrome advocates for collaborative care, highlights ongoing research on as-needed medicines, and underscores the importance of informed consent, emphasizing the necessity of understanding risks and benefits for enhanced communication and better quality of life for Alzheimer disease patients.

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Read the Transcript

Leslie Citrome, MD, MPH: Hello, I'm Dr Leslie Citrome, Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla, New York.

In my session, I'll be discussing the management of agitation associated with dementia, specifically Alzheimer disease. Alzheimer disease is common. About 7 million people in the US aged 65 and older are currently living with Alzheimer dementia, and by the year 2060, this number could double. About half the people with Alzheimer disease exhibit some degree of agitation.

Managing this at home is very important. We want to be able to get on top of this and be able to avoid the institutionalization that is often a consequence of agitation and rejection of care. When someone at home is rejecting eating, bathing, taking their medicine, and so on, it becomes very difficult for the caregiver to continue to provide that care, and that often leads to institutionalization, which is actually bad news for everybody.

A collaborative effort is imperative in the management of people with Alzheimer or other forms of dementia. This involves education, as well as an open line of communication with the various caregivers involved. This means learning all about the illness and its prognosis and the expectations. So, this means knowing something about behavioral interventions, which can be done at home. For example, making sure people are well-oriented, that the lighting is good. Having calendars and clocks handy is very useful. You'll see this actually in nursing homes where people are institutionalized. There's often clocks and calendars everywhere you go, and the name tags have the names in very large print so that there is no doubt as to who people are. Sometimes people with dementia get agitated because of some misperceptions or confusion, and very often, reorientation can help a great deal. Now, not everyone knows this. Not everyone is aware of the need to have good lighting and to orient people. This is the beginning of behavioral interventions.

Then there's knowing when to insist on things, when to back down—these are things that the caregiver can learn through interactions and knowledge from the providers as well as a variety of support organizations. It's important for the caregiver to know that they're not alone, they're not the first ones to go through this, and there is help available.

Over the past years, we've seen medications that seem to help with cognition, or at least prevent it from deteriorating as quickly. That is very limiting in what we can offer people with Alzheimer and other forms of dementia. There is investigation into disease-modifying treatments, but it's still too early to tell where that will lead us.

We now have treatments for agitation, specifically associated with Alzheimer disease. This is new. We've never had this before. One was approved by the FDA. It's called brexpiprazole, and it was tested in randomized controlled trials in people with Alzheimer disease who exhibited agitation. Brexpiprazole actually demonstrated reductions in agitation compared to placebo using a rating scale called the Cohen-Mansfield Agitation Inventory. This is good news. We now have something to offer that's FDA-approved.

Also being investigated is the potential for a [pro re nata (PRN)] or as-needed medicine. Now, the brexpiprazole I just mentioned is taken every day. What's needed is something that can be taken as needed, and dexmedetomidine sublingual film, already approved for agitation associated with schizophrenia or bipolar disorder, is being investigated for the use of agitation associated with Alzheimer disease.

These are good developments in that having FDA approval of interventions will make it easier to access these interventions, and it'll help our patients who are agitated more effectively when behavioral interventions have failed.

Ultimately, shared decision-making and informed consent will be the cornerstone of implementing new interventions. Families and patients need to be aware of the risks versus benefits of anything new that is being proposed to them. In the end, we'll have interventions that will be better than what we've had before, and enhancing the communication of these will make the lives of our patients better, and perhaps they can remain at home longer.

Leslie Citrome, MD, MPH, is clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York, and adjunct clinical professor of psychiatry, Icahn School of Medicine at Mount Sinai in New York City, New York. In addition to his academic positions, he has a private practice in psychiatry in Pomona, New York, and is a volunteer consultant to the Assertive Community Treatment team/Mental Health Association of Rockland County.