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Panel: Nonpharmacologic methods key for managing agitation in dementia

Helen C. Kales

An international consensus panel offered guidance on the most appropriate treatment approaches for managing behavioral and psychological symptoms — and agitation and psychosis — related to dementia, as well as the most promising treatments for the future in International Psychogeriatrics.

The panel found that the five highest ranking approaches for managing behavioral and psychological symptoms and agitation in people with dementia were non-pharmacological.

“There are 40 million people with dementia worldwide, most of whom are taken care of at home by family caregivers,” Helen C. Kales, MD, professor of psychiatry at University of Michigan, and from the VA Ann Arbor Healthcare System, told Healio Psychiatry. “While dementia is often thought about as a ‘memory’ disorder, behavioral and psychological symptoms like depression, anxiety, psychosis, hallucinations, wandering, aggression and agitation are universal and actually more problematic on a day-to-day basis for family caregivers. We sought to bring together the world’s leading experts on the behavioral and psychological symptoms of dementia to provide more specific guidance to clinicians on the best treatments, both current and future.”

Using the Delphi consensus process, an expert panel attended a prioritizing meeting at the 2015 International Psychogeriatric Association meeting to rank existing and up-and-coming treatments for behavioral and psychological symptoms in Alzheimer’s disease overall, and for agitation and psychosis. The panel comprised 11 international members with clinical and research expertise in the management of behavioral and psychological symptoms of dementia, who conducted two rounds of feedback via online survey, followed by an in-person meeting to confirm the outcome of the electronic process.

According to a press release, the five highest ranking treatments for agitation in people with dementia were non-pharmacological approaches. The panel found the following outranked any of the pharmacological treatments:

• assessment and management of underlying causes;
• educating caregivers;
• adapting environment;
• person-centered care; and
• a tailored activity program outranked any of the pharmacological treatments.

“The best treatments for most behavioral and psychological symptoms of dementia are non-drug treatments that emphasize the person, their caregiver and the environment,” Kales told Healio Psychiatry.

Citalopram, which ranked as number six, was the highest prioritized pharmacological treatment for behavioral and psychological symptoms of dementia. Meanwhile risperidone, which ranked as number seven, was the only currently used atypical antipsychotic medication that the expert panel agreed should be recommended for treatment, according to the release. The panel cited “minimal agreement on the use of alternative antipsychotics such as quetiapine or haloperidol.”

The most promising nonpharmacologic approaches to manage overall symptoms and agitation were the Describe, Investigate, Create and Evaluate (DICE) intervention — which provides a structured approach to examine underlying causes, care planning (ie, pharmacologic and nonpharmacologic strategies) and ongoing monitoring — and music therapy, according to the panel. They also presented dextromethorphan/quinidine as the most promising pharmacologic option for agitation.

The panel advised clinicians should conduct a thorough assessment and manage underlying causes as the first approach for treating psychosis in those with dementia, followed by recommending risperidone, which was the only pharmacological treatment with any supporting evidence, according to the release. The researchers noted that the gap in evidence for the treatment of psychosis in dementia emphasizes the need for further research.

“This research advocates a significant shift from current practice, recommending that nonpharmacological treatments are a first-line approach for agitation in dementia,” Kales said in the press release. “Aside from risperidone at number seven in the list, none of the other atypical antipsychotic drugs were recommended. This is a very welcome change, given the known harms associated with these treatments.” – by Savannah Demko

Disclosure: The authors report no relevant financial disclosures.