As an example of pressing unmet needs, Professor Banerjee identified effective treatments for agitation and depression, which are factors associated with dementia that substantially impair quality of life. These would complement any treatments we can develop to slow or stop the disease process and, ideally, restore previous levels of functioning. Simpler means of diagnosis, and reliable ways of differentiating AD from other forms of dementia, would also help.
The causes of agitation vary to some extent between long-term care and outpatient settings. Precipitating and perpetuating factors in a patient’s home and in an institution may differ, since the nature and extent of social interaction, for example, is not the same. In a care home, where a number of people live together, each may have their own set of problems. Loss of a patient’s home in itself may cause agitation. In a care home, it is important to understand the roles of leadership and management, as well as the direct delivery of care.
Agitation is a symptom, not a disorder in itself
Agitation is a particular behavior of an individual patient in a specific context. It is a symptom, not a disorder in itself, and may be caused by many factors. It may be due to an underlying physical problem or illness, rather than to interaction with family or formal carers, for example. It is important to find out the cause or causes in the case of an individual patient. What are the exact antecedents? How do we rule out physical illness? And, Professor Bannerjee emphasized, the problem of agitation can sometimes be in the eye of the beholder. It may be possible to reconceptualize the behavior so that it becomes tolerable.
How best to assess agitation depends on the services available. In the community, there is access to primary care, and then to secondary care services specialized in geriatrics and the mental health of the elderly. Services vary in the extent of their interest in agitation and skill in assessing it.
The likelihood of successful treatment may depend on the nature of the agitation. It is important to define what would constitute success in a particular patient. What is the outcome that you want? Then see if has been achieved.
Triggers for non-pharmacological or pharmacological interventions depend on the intensity of the agitation and the level of risk it poses in the particular situation. Non-drug treatment is based on identifying the causes and if possible modifying them. A period of watchful waiting is often a good starting point. This may mean changing washing and dressing routines, or changing the time at which a patient is woken. Many episodes of agitation are self-limiting or can be resolved.
But, if the agitation is causing a significant problem for the person with dementia, drug treatment is justified. This should be given at the lowest possible dose for the shortest possible time; and treatment must be reviewed regularly to see if the problematic behavior has disappeared.