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Behavioral and Psychological Symptoms of Dementia and Related Conditions

Agitation in Alzheimer's Disease

Publication

This issue of Insights & Implications in Gerontology provides an overview of agitation in Alzheimer’s disease (AAD) and outlines a process for assessing and treating the condition with a focus on collaborating with caregivers and, to the extent possible, individuals with AAD. It also shares implications from appropriate interdisciplinary care and how the lack of such care can be detrimental to individuals with AAD, their caregivers, and family members. AAD can occur along the entire spectrum of Alzheimer’s disease, but it is reported at higher rates in those with more severe dementia. It is also associated with many negative outcomes, including accelerated disease progression, physical and mental health deterioration, functional decline, and poor quality of life. This publication illustrates how proper treatment (from assessment to non-pharmacologic interventions and, if needed, pharmacologic treatment) can reduce the symptoms of agitation.

Podcast

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Agitation can be described as increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress. It may include nonaggressive behaviors such as pacing, repetitious movements, and general restlessness, or it may manifest as physically or verbally aggressive behaviors. It is one of the most distressing behavioral and psychological symptoms of dementia, and between 30% and 80% of people living with dementia, depending on the setting, experience agitation. Because of the wide-ranging potential negative impacts associated with agitation in Alzheimer’s disease (AAD), a person-centered, individualized approach to address AAD is a must. In this Momentum Discussion Podcast episode, we provide insights into AAD from the perspective of a professional caregiver and a family member whose loved one lives with AAD. They share how the condition impacts the person with Alzheimer’s disease and those around them and offer strategies to prevent and address troubling behavioral and psychological symptoms of dementia associated with AAD.

Guests: Laura Medders, LCSW
Administrative Director, Emory Integrated Memory Care Clinic

Maureen Morrison
Care partner to her husband, Angus, who lives with Alzheimer's disease

Host: Jennifer Pettis, MS, RN, CNE
Director of Strategic Alliances, The Gerontological Society of America

This podcast episode is supported by Otsuka. Content was developed by The Gerontological Society of America (GSA).

Decision Tree

Agitation in Alzheimer's Disease (AAD) impacts nearly 80% of persons with Alzheimer's Disease and is a cause of significant distress for patients and family/professional caregivers. The Agitation in Alzheimer’s Disease Decision Tree walks the clinician through a range of non-pharmacologic treatment options and highlights rational use of pharmacotherapies as well as their hazards in this vulnerable population. 

Informed by an expert panel, GSA developed the Agitation in Alzheimer’s Disease Decision Tree that was presented as a poster at the GSA Annual Scientific Meeting in November 2022 and recently updated to reflect the final International Psychogeriatric Association consensus clinical and research definition of agitation in cognitive disorders. 

Pseudobulbar Affect

Pseudobulbar affect (PBA) is a relatively common disorder in patients with neurologic conditions that can have a substantial negative impact on quality of life. Characterized by sudden bouts of uncontrollable crying and/or laughing that are disproportionate or inappropriate to the social context and are not associated with depression or anxiety, PBA is often underrecognized and undertreated. Treatment options available for PBA can reduce symptoms and improve quality of life, and coordinated care from the interprofessional health care team, along with the patient’s caregivers, can optimize management and outcomes for patients.  

Dementia-Related Psychosis

It is estimated that over 2 million Americans with dementia experience delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear). This group of symptoms, known as dementia-related psychosis, may cause significant distress to individuals and their families. Although common, the condition frequently goes undetected in people who may be struggling with other complex behavioral and psychological symptoms of dementia.

Podcasts

Part 1: Diagnosing Dementia-Related Psychosis

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Dementia-related psychosis, defined as hallucinations and delusions in individuals with dementia, is a distinct neuropsychiatric symptom. Dementia-related psychosis differs from psychosis that originates from delirium or a pre-existing psychotic disorder (e.g., schizophrenia). Dr. Gary Small explains the challenges to and approaches for detecting and diagnosing these symptoms. 

Guest: Gary Small, MD
Chair, Psychiatry at Hackensack University Medical Center; Physician in Chief, Behavioral Health; Chair, GSA’s Workgroup on Dementia-Related Psychosis

Host: Judit Illes, BCL/LLB, MS, CPHQ 
Director, Strategic Alliances, The Gerontological Society of America

This podcast episode is supported by Acadia Pharmaceuticals, Inc. Content was developed by The Gerontological Society of America (GSA).

Part 2: Dementia-Related Psychosis in Primary Care

Primary care providers (PCPs) are ideally positioned to recognize, diagnose, and provide care planning for individuals with dementia who experience psychosis. Dr. Alexis Eastman discusses the important role of PCPs in team-based approaches to care and shares examples of innovative healthcare delivery models that can support PCPs in addressing dementia-related psychosis.

Guest: Alexis Eastman, MD
Medical Director, Division of Geriatrics, University of Wisconsin Hospitals and Clinics; Associate Professor, University of Wisconsin School of Medicine and Public Health; Member, GSA’s Workgroup on Dementia-Related Psychosis

Host: Judit Illes, BCL/LLB, MS, CPHQ 
Director, Strategic Alliances, The Gerontological Society of America

This podcast episode is supported by Acadia Pharmaceuticals, Inc. Content was developed by The Gerontological Society of America (GSA).

Part 3: Dementia-Related Psychosis in Long-Term Care

Individuals with dementia-related psychosis experience worse outcomes than those who do not have psychosis, including but not being limited to accelerated time to being admitted to a long-term care facility and accelerated mortality. The manifestation of hallucinations and delusions in residents with dementia can also prove challenging for long-term care staff. Dr. Chad Worz discusses how appropriate documentation of a diagnosis of dementia-related psychosis and related care interventions are an important part of delivering individualized care for residents.

Guest: Chad Worz, PharmD, BCGP 
Executive Director and Chief Operating Officer, The American Society of Consultant Pharmacists (ASCP)

Host: Judit Illes, BCL/LLB, MS, CPHQ 
Director, Strategic Alliances, The Gerontological Society of America

This podcast episode is supported by Acadia Pharmaceuticals, Inc. Content was developed by The Gerontological Society of America (GSA).

Publications

Dementia-Related Psychosis: Strategies to Address Barriers to Care Across Settings

Dementia Related Psychosis Strategies to Address Barriers to Care Across Settings 1GSA’s February 2021 white paper identifies challenges that persons with dementia-related psychosis and their caregivers encounter as they move through different health care settings. The challenges and strategies to address them are based on input from experts in primary care, neurology, geriatric psychiatry, and nursing. Proposed strategies include improving communication about dementia-related psychosis with persons with dementia and their families, developing new educational initiatives to support primary care teams, and enhancing approaches to care coordination among primary and specialty care through telehealth and new models of care.

Dementia-Related Psychosis: Gaps and Opportunities for Improving Quality of Care

dementiarelatedpsychosis2019 1GSA’s August 2019 report brings attention to the need for greater awareness of dementia-related psychosis within the medical community and better support for those affected. Currently, there is no consensus in the medical community on how to diagnose dementia-related psychosis, which is clinically distinct from psychosis in other disorders (e.g., schizophrenia). Documentation and coding of the condition are also not standardized, making it difficult to identify, monitor and appropriately manage symptoms. This publication seeks to fill a gap in the available literature by summarizing best practices for treating dementia-related psychosis and proposing improvements to advance quality of care.

 

 

 

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