Special Feature
Management of Agitation and Aggression in the Elderly
By Lucy J. Puryear, MD
The treatment of elderly patients is often complicated by the need to manage behavioral disturbances associated with dementia. As medical advances continue to extend life, a larger percentage of the population will be at risk for the behavioral sequelae that may accompany dementia of any cause. Behavioral disturbances can include verbal outbursts, physical aggression, and wandering. These behaviors can be extremely difficult for caregivers to manage and often require an increased level of care, including nursing home placement along with physical and/or chemical restraints.
Although it is often problematic to assess a patient whose cognitive abilities make productive conversation difficult, it is important to try and identify the cause of the agitation or aggression and to treat any underlying disorder. Pain, anxiety, psychosis, delirium, or even boredom may all account for agitation. Masking the symptoms with sedating drugs, as opposed to treating the underlying condition, may cause further complications. Behavioral treatments should be considered as first-line therapies. These interventions would include reorientation, decreasing extraneous stimuli, and providing environmental cues.1 If these measures are inadequate, pharmacologic management should be added.
Typical Antipsychotics
Traditionally antipsychotic medications have been used to treat agitation and aggression. The typical’ antipsychotics, such as haloperidol (Haldol) or thioridazine (Mellaril), have often been used in large doses to sedate patients and decrease yelling, screaming, and wandering. Typical antipsychotics are useful medications but, because of potentially disabling side effects, should be limited to those patients with manifest psychotic symptoms such as auditory or visual hallucinations, or paranoid delusions. In the elderly patient, typical antipsychotics can be difficult to use. They carry a large anticholinergic burden, which may worsen cognitive symptoms. The elderly are also more sensitive to the extrapyramidal side effects of these medications, including akathesia, parkinsonism, and dystonias. These patients are also at greater risk for developing tardive dyskinesia, a serious, permanent movement disorder.
Newer, atypical’ antipsychotics are less likely to cause extrapyramidal symptoms and tardive dyskinesia. These newer medications include risperidone (Risperdal) and olanzapine (Zyprexa), and may be useful for the treatment of psychosis in the geriatric patient. Risperidone may be used in doses as low as 0.5 mg po at bedtime. There is the potential for orthostatic hypotension; blood pressure must be monitored and the dose should be increased slowly if necessary for symptom control. Above doses of 3-6 mg there is an increased incidence of EPS. Olanzapine should be used in doses of around 2.5 mg po at bedtime. This medication can cause marked sedation. Precautions must be taken to avoid falling at nighttime.
Benzodiazepines have been another frequent choice for the treatment of behavior problems in the elderly. In the geriatric patient, they pose particular problems and can increase memory impairment and confusion. They are also known to cause paradoxical disinhibition that may make aggressive behaviors worse. Benzodiazepines should be used in cases of acute agitation when quick control of the patient is essential. Low doses of 0.5-1.0 mg of lorazepam, po or IM, can be given every hour until symptoms remit. These medications should not be used for the control of chronic aggression.
Serotonergic Medications
Serotonergic medications have been used to treat agitation and aggression. Trazodone is a serotonergic antidepressant whose major side effect is sedation. Given at bedtime in the range of 25-50 mg po, it is a potent, nonaddicting hypnotic. Given in low doses throughout the day it may help control aggression.2 Buspirone is another serotonergic medication that can be used to control behavioral disturbance. It is marketed as an anxiolytic and is non-addicting. It may be a useful medication for the patient with anxiety as a major component of their agitation. Given by mouth, 5 mg twice or three times a day may alleviate restlessness. Higher doses may be used; However, it is necessary to observe patients for dizziness and mental confusion. The serotonin reuptake inhibitors fluoxetine, sertraline, paroxetine, and citalopram may also be effective in treating anxiety and aggression.3 These medications are typically well tolerated in the elderly, with starting doses of half the recommended initial dose.
Another class of medication, the anticonvulsants, has been used to control physical and verbal aggression in patients with dementia. Carbamazepine and sodium valproate (Depakote) have been shown to be safe in elderly patients. Liver function tests must be monitored and white blood cell count followed for patients on carbamazepine. Depakote is well tolerated, does not cause cognitive disturbance and may markedly diminish hitting and wandering. Blood levels can be monitored but elderly patients may do well on levels below the standard 50 ng/ml.4 Liver function tests and platelets must be followed when using this medication. These medications are obviously the drugs of choice when treating agitation or aggression due to the manic symptoms of bipolar disorder. They also may be particularly helpful in patients with impulsive aggressive behaviors such as striking out at caretakers.
Propanolol has been useful in high doses for the management of chronic aggression associated with brain damage.5 Dosing begins at 10 mg twice or three times a day and may go as high as 200 mg a day in divided doses. The anti aggressive effect may take several weeks to develop even after therapeutic doses have been reached. This medication must be used cautiously in the elderly due to it’s potential for causing hypotension and the potential for aggravating other medical conditions such as congestive heart failure and asthma. Its benefits are long-term behavioral control without cognitive side effects or the potential for addiction or abuse.
With careful consideration to the underlying reason for behavioral disturbances in the elderly, these behaviors can be successfully treated without additional side effect burden and potentially improve quality of life. Patients may be able to tolerate a less restrictive environment and decrease the risk of over sedation and other comorbidities of restraints.
References
1. Carlson DL, et al. Management of dementia-related behavioral disturbances: A nonpharmacologic approach. Mayo Clin Proc 1995; 70(11):1108-1115
2. Sultzer DL, et al. A double-blind comparison of trazodone and haloperidol for treatment of agitation in patients with dementia. Am J Geriatr Psychiatry 1997; 5(1):60-69
3. Tariot PN. Treatment strategies for agitation and psychosis in dementia. J Clin Psychiatry 1996; 57(Suppl 14):21-29
4. Kunik ME, et al. The efficacy and tolerability of divalproex sodium in elderly demented patients with behavioral disturbances. Int J Geriatr Psychiatry 1998;13(1):29-34.
5. Kunik ME, et al. Pharmacologic approach to management of agitation associated with dementia. J Clin Psychiatry 1994;55 Suppl:13-17
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