Introduction

Agitation and restlessness is poorly understood in older adults, but is generally considered to have multifactorial etiology, including genetics, physical disease, changes in the brain, unmet needs, and unaddressed pain.1 Agitation and psychosis are common among older adults with dementia, with 80% of patients presenting with neuropsychiatric symptoms.2 Agitation and psychosis are important clinical problems as they decrease patient and caregiver quality of life and are a frequent contributor to caregiver’s decisions to admit older adults with dementia to long-term care facilities.2 Symptoms of agitation and restlessness are also difficult for health care providers to manage. These symptoms commonly co-exist with acute or chronic pain in older adults and may present in response to an underlying, uncomfortable condition. It may be difficult for nurses and providers to identify the cause of an elderly patient’s agitation. As older persons with dementia have fewer skills to communicate, they may exhibit signs of agitation, restlessness, and aggression in response to a host of underlying factors and frustrations that are not easily differentiated.1

Interprofessional Assessment and Collaborative Interventions

Untreated pain frequently results in agitated and restless behavior among older adults. With advancing age comes high prevalence of pain resulting from complex medical conditions such as musculoskeletal disease, neuropathic disorders, cancer, vascular disease, and chronic wounds.1 Community-dwelling older adults with dementia and physical manifestations of pain have been identified at increased risk of developing aggression.3 Nurses and providers are encouraged to perform frequent assessment and reassessment of pain based on observations of patients’ non-verbal behavior and physiological changes, including alternations in facial expression, vital signs, sleep patterns, appetite, presence of guarding, and sweating.2 Family members and caregivers can assist in identifying manifestations of underlying pain in patients with dementia and alerting providers to changes from patient’s baseline that may indicate an underlying condition causing agitation.

Treatment of these symptoms can be challenging for clinicians. Although non-pharmacological interventions are recommended as first-line treatment, many providers will address agitation with use of antipsychotics, antidepressants, neuroleptics, and analgesics.1,2 These treatments are not without controversy. While atypical antipsychotics are most extensively prescribed in treatment of agitation and psychosis, they are likely to increase risk of mortality in patients with dementia.2 Use of neuroleptics has also been linked to increased mortality and risk of cerebrovascular accidents in this population.1 Treatment with sedatives may mask symptoms related to pain, further hindering treatment.3 Geriatric psychiatrists and other dementia specialists are encouraged to educate hospital staff regarding early identification and investigation into causes of agitation and restlessness in older adults. Pharmacists should also be consulted when selecting medications for treatment, as provider often have concerns regarding patients’ ability to tolerate analgesics given physiological changes of aging, which may contribute to undertreatment of pain in older adults.3 Social workers will also aid in post-discharge placement for the vulnerable patients.

Interprofessional contacts for this topic:

Acute care providers

Geriatric psychiatrists

Primary care providers

Pharmacists

Registered nurses

Social workers

Link to the following evidence-based protocols:

Assessing cognition

Medication

Pain

References

1Husebo, B.S., Ballard, C., & Aarsland, D. (2011). Pain treatment of agitation in patients with dementia: A systematic review. International Journal of Geriatric Psychiatry, 26(10), 1012-1018.

2Seitz, D.P., Adunuri, N., Gill, S.S., Gruneir, A., Herrmann, N., & Rochon, P. (2011). Antidepressants for agitation and psychosis in dementia. Cochrane Database of Systematic Review, 2, 1-31.

3McAuliffe, L., Brown, D., & Fetherstonhaugh, D. (2012). Pain and dementia: An overview of the literature. International Journal of Older People Nursing, 7(3), 219-226.