Agitation

Course Leader

Elizabeth (Dr Liz) has over twenty years of experience in providing medical care to the elders. She is board-certified in Internal Medicine, Geriatric Medicine and Palliative Care Medicine. Dr Landsverk founded ElderConsult Geriatric Medicine, a house calls practice, to address the challenging medical and behavioral issues often facing older patients and their families.

Dr Landsverk was an assistant professor of Medicine at University of California, San Francisco, an adjunct professor of Medicine at Stanford University, as well as consultant to the San Francisco Elder Abuse Forensics Center and Hospice Medical Director. She is currently the Medical Director for Silverado and Kensington Dementia Care Communities, as well as on the Scientific Panel for the Alzheimer’s Association. Dr Landsverk graduated from Stanford University, and trained at Cambridge Hospital, Harvard University, and Mt Sinai Medical School.

As a House Calls Geriatrician, she collaborates with local physicians to address the needs of complicated vulnerable elders to alleviate pain, agitation and discomfort through the utilization of geriatric and palliative care techniques.

Learning Objectives 

Lesson 1 – Why is Ativan not the Answer

This lesson discusses the commonly used medication Ativan, and explores Dr Liz’s perspective as to why it is not always the best course of treatment for elders with dementia. 

On completion of this lesson the learner will: 

1. Understand reasons why using Ativan for dementia related agitation may not be the most effective or appropriate treatment. 

Lesson 2 – The Problem with how we use Anxiety Pills

This lesson explores statistics around prescribing demographics of anti anxiety medications, alongside examination of general issues with anti anxiety medications. 

On completion of this lesson the learner will:

1. Understand the prevalence of anti anxiety medication prescriptions in the general population and specific groups.
2. Be aware of issues related to tolerance and withdrawal encountered by people taking anti anxiety medications.

Lesson 3 – Dementia No-No’s: Caffeine and Alcohol

This lesson discusses the negative effects of alcohol and caffeine on the behaviour of people with dementia. Potential techniques for moderating alcohol and caffeine intake such as dilution are discussed. 

On completion of this lesson the learner will:

1. Understand the potential negative effects of alcohol and caffeine may have on elders with dementia, in particular reference to agitation and sleep disturbance. 
2. Be aware of some effective strategies to moderate use of caffeine and alcohol. 

Lesson 4 – Troubleshoot What may be Causing Agitation

This lesson explores issues that can cause agitation in elders with dementia. The role of boredom, overstimulation and pain is discussed. The role of engagement and physical activity as a positive tool is examined.

On completion of this lesson the learner will:

1. Understand potential triggers of agitation in elders with dementia
2. Understand the positive role of physical activity and engagement in preventing agitation. 

Lesson 5 – Consult a geriatrician to look over Medications

This lesson addresses the value of an experienced geriatrician assessing the elder’s medications in order to stop any that can increase agitation. The role of anti cholinergic medications in agitation is discussed. 

On completion of this lesson the learner will:

1. Be aware of the role of the geriatrician in reviewing and amending prescriptions to improve patient well-being.
2. Understand the effects that different drugs and medicines may have on agitation in elders with dementia.

Lesson 6 – The Importance of Engagement in Dementia Care

This lesson explores the importance of engagement in meaningful activity for people with a diagnosis of dementia. Different activities with engagement of the elder are discussed. The value of active engagement in activities such as baking or playing games is compared with passive engagement such as in a music performance. The potential for engagement in activities to affect behaviour is discussed. 

On completion of this lesson the learner will: 

1. Understand the benefit of engaging elders in activities
2. Understand the positive effect the activities could have on behaviour. 

Lesson 7 – Could it be Infection?

This lesson explores potential physical causes of agitation. Urinary tract infection is discussed, with a caution against over diagnosis. Pneumonia, prostate enlargement/ infection and tooth abscesses are also covered. Pressure damage is explored, with advice on how to prevent pressure ulcers. The importance of physical activity and mobility on preventing pressure damage is emphasised. 

On completion of this lesson the learner will:

1. Be aware of physical conditions that may cause agitation and how these may present in elders with dementia.
2. Understand the importance of mobility and physical activity in preventing physical causes of agitation.

Lesson 8 – Dementia care 101: Don’t Simply Restrain Elders. 

This lesson discusses the increased incidence of agitation and aggression when elders are routinely restrained. The positive effect of care being delivered in the right setting for the patient alongside provision of space to wander is discussed in relation to reducing agitation.  The presence of agitation not related to unmet needs is acknowledged. 

On completion of this lesson the learner will:

1. Understand the role that restraint plays in increasing agitation
2. Be aware of the potential positive impact of provision of space and minimal restriction. 

Lesson 9 – Dealing with Delusion and Paranoia

This lesson examines times at which delusion and paranoia may need to be treated with medication. Focus is placed on when essential medical procedures are required, and cautions and limitations of medications are explored. Necessity of medical procedures is discussed, with an emphasis on carrying out only procedures that will immediately improve condition or quality of life. 

On completion of this lesson the learner will:

1. Be aware of times when medications may be required to control delusion or paranoia
2. Understand the cautions and limitations of use of medications in these scenarios
3. Understand the importance of advocating for elders to undergo only essential medical procedures. 

Lesson 10 – Antidepressants in Dementia Care 

This lesson discusses the role of antidepressants in dementia care. The widespread presence of irritability in elders with dementia is acknowledged. The occurrence of depression in early dementia due to knowledge of diagnosis and disease progression is discussed. The suitability of Zoloft / Citalopram is discussed. The unsuitability and risk for increased agitation in other kinds of antidepressant is explored. 

On completion of this lesson the learner will:

1. Be aware of common psychological symptoms that can be improved by antidepressant administration.
2. Understand which antidepressants are suitable for elders with dementia, and which may exacerbate symptoms of agitation. 

Lesson 11 – Antipsychotics in Dementia Care

This lesson discusses the use of antipsychotics when treating people with dementia. Emphasis is placed on the use of extreme care in use of these drugs for elders with dementia. Medical research in relation to this lesson is discussed, in reference to opposing viewpoints. Dr Liz explores real world use of these drugs, placing focus on quality of life and enabling elders to live comfortably at home or in a home like facility. 

On completion of this lesson the learner will: 

1. Be aware of times antipsychotics should and should not be used to treat elders with dementia
2. Understand the differing opinions in the geriatrician community in relation to use of these drugs. 

Lesson 12 – The Best Care: Dementia Communities 

This lesson explores facilities of care for elders with dementia who experience agitation or delirium. Challenges to admission for these patients, alongside premature hospice care and poor outcomes are discussed. The role of dementia communities and borden houses are explored.

On completion of this lesson the learner will: 

1. Understand the challenges in admission to traditional facilities and resultant poor outcomes experienced by people with dementia who experience delusions and agitation. 
2. Be aware of the role played by dementia communities and borden houses in providing care for these patients. 

Lesson 13 – FDA Approved Medications in Dementia Care

This lesson discusses the lack of FDA approved medications for treating patients with dementia experiencing agitation. Dr Liz discusses the use of American Psychological Association (APA) medication guidelines in her practice – particularly stopping all unsuitable or unneeded medications, treating pain, and promoting behavioral interventions. The need for psychoactive medications is discussed only after following these steps and if the elder is a danger to themselves or others. 

On completion of this lesson the learner will: 

1. Be aware of the lack of FDA guidance or regulation in relation to medications for dementia related agitation. 
2. Understand the APA medication guidelines for managing agitation in dementia.  
3. Understand the potential need for psychoactive drugs in extreme cases. 

Lesson 14 – Is it Safe to Take Drugs Then Drink Alcohol?

This lesson addresses a question from a learner in relation to taking medications and drinking alcohol. The potential negative effects of medications combined with alcohol are discussed. The need to find out if an elder has capacity is emphasized. The potential role of a caregiver in regulation of alcohol intake is discussed. 

On completion of this lesson the learner will:

1. Understand the potential negative effects of combining medications and alcohol.
2. Be aware of the potential need for caregivers to regulate alcohol supply and intake.