Abstract
Purpose of Review
This paper aims to describe the heterogenous presentation of agitation in older adults. It will delve into semiology, diagnosis, classification, as well as treatment options available to address agitation.
Recent Findings
Agitation is a common and distressing symptom that poses risk to patients and caregivers. In older adults, it is often a manifestation of medical and neuropsychiatric conditions such as dementia, stroke, delirium, psychiatric disorders, catatonia, substance intoxication or withdrawal. Agitation in dementia is defined as excessive motor behavior and verbal or physical aggressive behavior, causing significant disability. Several tools are used to describe it; most notably, the Cohen-Mansfield Agitation Inventory (CMAI). Its evaluation is most complete with the DICE (Describe, Investigate, Create, Evaluate) approach which allows for examination of precipitating factors such as delirium, psychiatric disorders, pain, polypharmacy, constipation, environmental elements, and others. Non-pharmacological management should be attempted first, tailoring the treatment to the precipitants. If these fail, pharmacological treatments, although inherently risky, include non-emergent and emergent options. The former are antidepressants and cognitive enhancers, and the latter include antipsychotics, trazodone, and electroconvulsive therapy (ECT). Benzodiazepine use should be limited to excited catatonia or alcohol withdrawal.
Summary
Agitation management is as much about addressing unmet needs as it is about treatment of underlying etiologies. A careful and systematic approach is imperative to successful treatment. It allows the clinician to uncover what the patient is unable to convey and minimizes the risk that polypharmacy may bring. More research is needed into methods to quantify, anticipate, and safely treat agitation in older adults.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
According to data from the National Center for Health Statistics, during 2014–2017, approximately 20% of all emergency department visits in the United States were made by adults aged 60 and over [1]. As the population of older adults grows to a predicted 98 million by the year 2060, rates of dementia are also projected to rise, and an increase in emergency department utilization by this group will likely follow [2]. Agitation is a common concern for which older adults present to the emergency department. Older adults with agitation are brought to the emergency department when behaviors can no longer be safely managed at home or in a long-term care facility [3]. In older adults, agitation often manifests within the context of an underlying medical and/or neuropsychiatric condition, such as dementia, stroke, delirium, psychotic disorder, catatonia, substance intoxication or withdrawal [4]. When specifically related to dementia, agitation leads to poorer overall outcomes for patients and caregivers [5]. The rate of cognitive and functional decline increases as well as the rate of economic and social burden for the caregivers.
Agitation which is disruptive, aberrant, or bothersome but does not place anyone in imminent danger is considered “non-emergent” and can be managed in the ambulatory setting over the course of days to weeks [6]. Non-pharmacological strategies for managing non-emergent agitation in older adults are considered first-line and include behavioral and environmental modifications and medical interventions [6]. If such interventions have been utilized and the behavior escalates, placing the patient and/or others at imminent risk of harm, the agitation should be considered “emergent,” necessitating rapid de-escalation [6]. In these cases, time-limited pharmacological management is often needed, but only after careful consideration of the risks and benefits associated with use and close monitoring for adverse side effects [7]. Meta-analyses have evaluated the use of antipsychotics, benzodiazepines, anticonvulsants, and antidepressants, and some agents have shown efficacy over placebo for favorable behavioral outcomes [8]. However, there are limited data to support the safety of these agents in terms of mortality outcome measures, hence the lack of FDA-approval for this indication [7].
This article describes the identification, classification, and evaluation of agitation in older adults as well as which treatment modalities may be appropriate for short-term versus long-term management. The risks and benefits of different treatment modalities will be reviewed, including non-pharmacologic and pharmacologic as well as emergent and non-emergent. While this article focuses primarily on agitation associated with cognitive impairment, many of the proposed strategies can be applied to agitation secondary to any medical or neuropsychiatric condition.
Clinical Presentation
The term agitation is a broad umbrella-term that has been variably and vaguely defined. The term may be used to describe presentations ranging from repeated questioning to physical aggression. It follows the heterogenous nature of disruptive behaviors across cognitive impairment and as such requires very specific description of the behavior to adequately define and treat it. In line with recent consensus criteria [9], we define agitation as excessive motor behavior or verbally or physically aggressive behavior causing significant disability. Disability could be within interpersonal relationships, other aspects of functioning, or interfere with patients’ ability to perform and participate in activities of daily living.
Using the framework established by the Cohen-Mansfield Agitation Inventory (CMAI), agitation can be clustered into physically aggressive agitation, physically nonaggressive agitation, verbally aggressive agitation, verbally nonaggressive agitation [10]. The CMAI allows for screening and frequency monitoring of 29 distinct behaviors (Table 1) [10]. A recently validated observational variant of the CMAI has also shown promising results in using this tool by observants who are not familiar with the subject [11].
Evaluation of the Older Adult with Agitation
In 2011, a multidisciplinary expert panel developed the Describe, Investigate, Create, Evaluate (DICE) approach for evaluating and treating neuropsychiatric symptoms of dementia [12]. Although developed specifically for patients with dementia, this general framework can be useful for evaluating any older adult with agitation—dementia, after all, is underdiagnosed, particularly in non-white individuals [13]. Using the DICE approach, witnesses to the behavior such as caregivers, staff, or the patient themselves if possible, should first describe the behavior.. It is important to determine whether there is a known diagnosis of dementia or cognitive impairment, the time course/chronology of the behavior, the severity of the behavior, and the individual’s premorbid personality. Since agitation encompasses a broad range of problematic behaviors, a number of rating scales have been developed, including the CMAI described above [14,15,16], the Overt Agitation Severity Scale (OASS) [17], the Behavioral Activity Rating Scale (BARS) [18], and the Neuropsychiatric Inventory-Clinician Rating Scale (NPI-C) [19]. Some scales are more suited to certain settings than others: the BARS, for example, is easy to complete and can be used in a nonmedical setting, such as an assisted living center [20], while the NPI-C must be completed by a clinician.
Next, possible underlying causes of the behavior, such as dementia [21, 22], delirium [23], depression [24], pain, constipation [25], and environmental factors [12] should be investigated. Delirium is notoriously underdiagnosed despite having an occurrence rate between 11 and 42% per admission [26]. Delirium is caused by an acute medical illness or substance/drug effect [23, 27, 28], the latter risk compounded by high rates of polypharmacy in the geriatric population [29]. Delirium often presents similarly to dementia but is differentiated by its acute, fluctuating, and typically reversible nature. Collateral history obtained from caregivers regarding the patient’s baseline personality and cognitive abilities can be helpful in differentiating delirium from dementia [30]. Moreover, delirium is often superimposed on dementia: a prospective cohort study of geriatric patients admitted to a Scotland hospital found that almost half of patients with known dementia developed delirium during their admission [31]. Primary psychiatric disorders such as depression can also present with agitation, particularly in older adults [32]. Given their cognitive challenges, patients with dementia are less able to communicate their pain and are thus often undertreated, leading to prolonged distress and agitation [25]. Treating pain in older adults, such as in the postoperative setting, can be challenging given the age-associated changes in opioid pharmacokinetics and pharmacodynamics and unwanted side effects such as nausea, constipation, urinary retention, and pruritis, all of which can themselves lead to agitation [33]. Environmental factors may also be a source of agitation. The constant bustle of the emergency room may be overstimulating, or conversely the patient may not have access to their hearing aids, leading to increased confusion. Behaviors that occur at home but stop upon admission to the hospital suggest that the home environment may be a source of agitation, perhaps due to increased caregiver burden leading to confrontational interactions or even elder abuse [12, 34,35,36,37].
Given the broad differential for agitation in the older patient, it is important to perform a careful physical exam, including vital signs and a neurological exam, as well as obtain laboratory data such as blood electrolyte and glucose levels, complete blood counts, and a urinalysis. Imaging or electroencephalogram (EEG) may be necessary as well in the case of suspected trauma/stroke or seizure, respectively. It is important to quickly obtain these objective data, since an agitated presentation along with other factors such as baseline cognitive impairment or lack of collateral information from caregivers may prevent obtaining a detailed history. Objective data should also be interpreted carefully in older adults: infection, for example, is known to present differently in this population due to age-related changes in the immune system and thermoregulation amongst other factors [38]. Substance use or withdrawal are often overlooked causes of agitation in older patients. A patient who becomes agitated days after surgery could be undergoing alcohol withdrawal; a sudden change in vital signs would be an important clue [39]. A medication inventory, including over the counter medications and supplements, should be taken for all patients, since delirium-inducing medications like benzodiazepines, non-benzodiazepine hypnotics, tricyclic antidepressants, and other medications with anticholinergic properties continue to be prescribed to older adults [40].
Older patients can develop agitation in a variety of settings, from the emergency department to the surgical service. It is therefore crucial for all medical providers to begin the evaluation of the agitated older adult as soon as possible so as to not delay workup and treatment. Psychiatric evaluation is recommended if non-pharmacological management is insufficient and pharmacological interventions must be initiated. In these cases, early involvement by a geriatric specialist such as a geriatrician or geropsychiatrist is critical to avoid interventions that may be harmful to the elderly. A virtual consultation with these specialists may be an option in resource-limited healthcare settings. A formal psychiatric evaluation may also help with clarifying diagnosis, which would aid disposition planning. Determining the disposition of the acutely agitated patient—i.e., medical or psychiatric admission—can be complicated, with transfers between medical and psychiatric services even more so, with potential for bias. A study of transfers to a psychiatric hospital in Greece, for example, suggested that patients on medical or surgical services with poor family support or an existing psychiatric diagnosis were more likely to be transferred to psychiatry [41].
In general, patients with an acute medical illness requiring treatment should be admitted to a medical service, while patients whose agitation is likely due to underlying dementia or a primary psychiatric disorder can be admitted to a psychiatric service if there is an immediate risk of harm. Regardless of where the patient is admitted, disposition planning should begin immediately, since older patients with behavioral symptoms are likely to require a higher level of care upon discharge [27]. If the patient requires the appointment of a legal guardian, this process should be initiated quickly, since petitioning the courts can prolong the patient’s length of stay, with the risk of additional hospital-acquired complications [42].
Non-Pharmacologic Management
Using the DICE approach, the next steps in managing agitation include creation and evaluation of a comprehensive treatment plan. Agitation in the older adult that does not pose a threat of immediate harm should be managed with non-pharmacologic strategies before attempting pharmacologic treatment. This includes eliminating triggers specific to the patient, improving sleep hygiene, and supporting the caregiver [12]. Abraha et al. conducted a systematic overview of non-pharmacologic treatments for behavioral symptoms in dementia. The strongest evidence exists for the use of music therapy to reduce agitation, aggression, and anxiety, as well as formal caregiver training and dementia care mapping, in which caregivers attempt to place themselves in the shoes of the patient with dementia—especially when supervised by a healthcare professional [43, 44]. While a variety of other non-pharmacological therapies exist, these have limited proven efficacy, possibly due to the relative heterogeneity of their implementation compared to pharmacologic treatments [43]. Non-pharmacologic treatment strategies should be tailored to the individual patient. A lifelong pet owner, for example, may show improvements in behavioral symptoms after a session of pet therapy, despite the overall evidence basis for pet therapy being weak. Interventions as simple as providing amplifiers to patients who are hearing impaired may improve anxiety levels during hospitalizations. Ultimately, the successful implementation of non-pharmacologic interventions requires time and creativity: time for the care team to get to know the patient and caregivers and creatively modify the patient’s hospital experience to reduce stressors and bring to them some of the joy from the outside world [12]. Simple interventions may include giving the patient a doll, playing music familiar to the patient, assigning the patients tasks that highlight the abilities they have retained like folding towels, helping to organize the bed, or drawing.
Not all non-pharmacologic interventions for agitation are without risk. The use of physical restraints has come under significant criticism due to ethical concerns as well as the risks, including falls, fractures, and decubitus ulcers from immobilization [45]. A cohort study of patients in the intensive care unit found that of patients who had been physically restrained, almost 40 % developed delirium, with the risk increasing by over twenty-six times when patients were restrained for six days or more [46]. A cross-sectional study of patients presenting to the emergency department with agitation identified two clusters of patients for whom physical restraints were often used: younger males with psychiatric illness and/or substance use and those experiencing homelessness and older adults presenting with medical concerns who did not follow commands [47]. Patients are more likely to be restrained in the emergency department than on an inpatient unit [48]; prioritizing the transfer of older patients from the emergency department would likely mitigate these harmful effects, while also reducing the incidence of delirium [49].
Another non-pharmacological intervention that has come under scrutiny is the practice of seclusion. A study of patient experiences in psychiatric settings revealed that being placed in seclusion had almost the same likelihood of being “severely or extremely distressing” to these patients as being placed in restraints [50]. Unlike pharmacological options for sedating severely agitated patients, restraints and seclusion carry the risk of being used for longer than necessary, especially in a busy hospital setting. Given the risks of injury and overuse and the availability of pharmacological options for rapid sedation in emergencies, restraint and seclusion should be avoided whenever possible.
Pharmacological Management and Neuromodulation
Although non-pharmacological interventions for agitation are decidedly safer than pharmacological ones, patients who pose an immediate threat to themselves or others or whose agitation compromises necessary medical care will likely require the latter. Pharmacologic treatment should also be considered in patients who fail non-pharmacologic interventions and in those who have an underlying primary psychiatric disorder. Medications that can be used to treat agitation in older adults include antipsychotics, antidepressants, and sedatives, although it is important to note that no medications are FDA-approved for agitation. Each class of medication has various degrees of evidence basis, benefits, and risks. Treatment response should be monitored with the agitation scales described above.
For patients with dementia and/or an underlying psychotic disorder, the antipsychotics risperidone, olanzapine, and aripiprazole can be effective in treating behavioral symptoms. Quetiapine, while often used in clinical practice, has a poorer evidence base for use in patients with dementia [5]. One advantage of quetiapine is that it has a lower risk of inducing extrapyramidal symptoms (EPS) compared to risperidone and olanzapine [51] and therefore may be a better medication for patients with diagnosed or suspected synucleinopathy such as Parkinson’s disease or Lewy body dementia. Antipsychotics as a class have come under scrutiny for increasing the risk of cardiovascular events and mortality in patients with dementia. Compared to risperidone, ziprasidone and quetiapine appear to have a lower risk of these major adverse cardiovascular events [52]. Haloperidol, a common and relatively cost-effective [53] first-generation antipsychotic used to treat acute agitation, has a higher risk of major cardiovascular events in these patients and should be avoided in the geriatric population given the risk of EPS as well [52]. If absolutely necessary, haloperidol should be given at the low dose of 0.5 mg; higher doses do not appear to reduce the duration of agitation but do however increase the risk of side effects [54]. The atypical antipsychotic olanzapine can be given by mouth or sublingually with an onset of 15–120 min. If a more rapid response is required, it can be given intramuscularly or intravenously with an onset of 15–30 min. For patients with a diagnosed synucleinopathy, quetiapine has an onset of 30–90 min; for rapid treatment in this population, lorazepam can be given intramuscularly or intravenously, though benzodiazepines carry their own risks [2]. Given the risks of antipsychotic use in patients with dementia, they should be reserved for periods of acute or severe agitation with consideration given to taper and discontinue once the patient has achieved a period of behavioral stability. Some patients with severe behavioral symptoms may relapse upon antipsychotic discontinuation [5], at which time a decision should be made regarding risks and benefits of long term antipsychotic treatment.
The atypical antidepressant trazodone has sedative properties and improves sleep parameters but does not consistently improve agitation in patients with dementia; anecdotally, we find that it can be helpful on an “as needed” basis for non-emergent agitation. It is also possible that in certain patients for whom lack of sleep is the primary cause of their agitation, trazodone may be effective in reducing agitation. Anticonvulsants such as valproic acid, carbamazepine, and gabapentin do not consistently improve agitation in patients with dementia but do have many adverse effects; therefore, we recommend against their routine use in the absence of an underlying bipolar disorder. A randomized clinical trial has been designed to evaluate the use of lithium to treat agitation and aggression in patients with Alzheimer’s disease [55].
Benzodiazepines are commonly used to treat agitation in patients with dementia, but no meta-analytic data demonstrate efficacy in these patients [5]. The use of benzodiazepines in older adults is fraught with complications such as delirium, falls, and fractures, and should be avoided [40, 56]. Exceptions include catatonia and alcohol withdrawal. The excited type of catatonia presents with symptoms ranging from agitation to autonomic dysfunction and can be deadly if left untreated [57, 58]. Benzodiazepines, often administered parenterally, are effective in treating acute catatonia [59]. Alcohol withdrawal syndrome, an often-overlooked diagnosis in older patients, can also present with agitation and autonomic symptoms. Benzodiazepines have been the standard treatment for alcohol withdrawal for decades with a wealth of evidence showing their safety and efficacy when used for this purpose [60, 61].
When patients with dementia become severely agitated and fail pharmacological treatment, another option is electroconvulsive therapy (ECT). A systematic review of the evidence for ECT being used for this purpose suggested that most patients show early benefit with few side effects. However, none of the included studies were randomized control trials and suffer from selection bias [62]. The only prospective study included in this review did not follow a control group, such as pharmacotherapy only, limiting the strength of its findings [63]. Numerous studies have attested to the safety of ECT in various geriatric patient populations [64], but large randomized studies are still needed.
Non-Emergent Pharmacologic Management
Antidepressants, the first line pharmacologic treatment for older adults with depression and anxiety disorders, have a slow onset of action but can also be used in the long term to treat symptoms of agitation in patients with dementia. Selective serotonin reuptake inhibitors (SSRIs) like citalopram and sertraline are effective at reducing agitation [5]. A clinical trial of citalopram for treating neuropsychiatric symptoms in patients with Alzheimer’s disease found that the subgroup of patients with primarily affective symptoms benefited most. However, there were troublesome side effects such as QT prolongation and cognitive worsening [65], which further studies found to be associated with the R-enantiomer of the drug, while the S-enantiomer was associated with the most benefits [66]. Hence, a trial was designed for the use of escitalopram in this population [67]. Prior to initiating citalopram in older patients, it would be helpful to obtain a baseline electrocardiogram and monitor QT interval periodically.
There is emerging evidence that cannabinoids may be useful in treating agitation in older adults with dementia. A double-blind crossover randomized control trial demonstrated the efficacy of nabilone, a synthetic oral tetrahydrocannabinol (THC) analogue that acts as a partial agonist at CB1/2 receptors, in reducing agitation in patients with moderate-to-severe Alzheimer’s disease over a six-week long treatment period [68]. Notably, nabilone was superior to risperidone [69], SSRIs, trazodone [70], and other cannabinoids like THC [71] and dronabinol [72], a full agonist at CB1/2 receptors. However, this trial did note the frequent side effect of sedation, possibly due to the advanced age of the participants, but with no worsening of cognitive function. Only 38 patients were included in this trial, but its results offer a promising alternative to other pharmacological options [68]. Dextromethorphan-quinidine, an approved treatment for pseudobulbar affect, is another candidate medication for the treatment of agitation in patients with dementia [73]. A randomized controlled trial comparing dextromethorphan-quinidine to placebo did reveal an increased risk of falls in patients taking this medication but no increased risk of sedation, cognitive impairment, or QT prolongation [74]. Further studies are needed to confirm its safety and efficacy in the elderly population.
Cholinesterase inhibitors and the NMDA glutamate receptor antagonist memantine are other options for treating non-emergent agitation in patients with dementia [75]. Cholinesterase inhibitors may be particularly helpful for patients with Alzheimer’s disease or Lewy body dementia [76]. A randomized controlled trial conducted over a twelve-month period found that patients with Alzheimer’s disease receiving memantine, rivastigmine, or donepezil, but not galantamine, experienced significant improvement in their neuropsychiatric symptoms [77]. A retrospective study found that six months of treatment with memantine in addition to a cholinesterase inhibitor resulted in improvement in agitation scores in 80% of patients [78]. Cholinesterase inhibitors as well as memantine can have some unpleasant side effects such insomnia and gastrointestinal distress but are otherwise generally well-tolerated [75].
Table 2 summarizes pharmacologic treatment options for emergent and non-emergent agitation, with available routes and recommended dosing in the geriatric population [75, 79,80,81,82] For patients who are more frail, suggested by their body mass index (BMI), vital signs, mobility, comorbidities, or medications, the lower dose is recommended [79].
Conclusion
Agitation in the older adult is a common concern with significant consequences, particularly for patients with neurocognitive disorders and their caregivers. Management of agitation begins with the identification and description of the specific behaviors of concern, ideally using validated rating scales, followed by a thorough evaluation to identify potential unmet needs and contributing factors. The treatment of agitation should be tailored to the individual, beginning with non-pharmacologic management, including addressing any underlying contributors and providing caregiver education and support. Pharmacologic and neuromodulation treatment options have shown some efficacy though none are FDA-approved, and risks/benefits must be carefully weighed. Effects of treatment should be monitored and the need for medication re-evaluated periodically. As is frequently the case in caring for complex older adults with neuropsychiatric illness, a systematic, biopsychosocial approach by a multidisciplinary care team can ensure patient-centered care in the optimal setting.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Ashman JJ, Schappert SM, Santo L. Emergency Department Visits Among Adults Aged 60 and Over: United States, 2014–2017, NCHS Data Brief No. 367. Hyattsville, MD; 2020.
•Kennedy M, Koehl J, Shenvi CL, Greenberg A, Zurek O, LaMantia M, et al. The agitated older adult in the emergency department: a narrative review of common causes and management strategies. J Am Coll Emerg Physicians Open. 2020;(March):812–23. This recently published article is a helpful review of the approach to evaluating and treating the agitated older adult who presents to the emergency department.
Maust DT, Kales HC, McCammon RJ, Blow FC, Leggett A, Langa KM. Distress associated with dementia-related psychosis and agitation in relation to healthcare utilization and costs. Am J Geriatr Psychiatry Off J Am Assoc Geriatr Psych. 2017;25(10):1074–82.
Bessey LJ, Radue RM, Chapman EN, Boyle LL, Shah MN. Behavioral health needs of older adults in the emergency department. Clin Geriatr Med. 2018 Aug;34(3):469–89.
••Tampi RR, Tampi DJ, Balachandran S. Antipsychotics, antidepressants, anticonvulsants, melatonin, and benzodiazepines for behavioral and psychological symptoms of dementia: a systematic review of meta-analyses. Curr treat options Psychiatry [Internet]. 2017;4(1):55–79. Available from: https://doi.org/10.1007/s40501-017-0104-2. This systematic review is a comprehensive overview of the evidence base for various pharmacologic strategies for the management of agitation in dementia.
Chen A, Copeli F, Metzger E, Cloutier A, Osser DN. The psychopharmacology algorithm project at the Harvard south shore program: an update on management of behavioral and psychological symptoms in dementia. Psychiatry Res. 2021 Jan;295:113641.
Tampi RR, Williamson D, Muralee S, Mittal V, McEnerney N, Thomas J, et al. Behavioral and psychological symptoms of dementia: Part II-treatment. Clin Geriatr. 2011;19(6).
••Yunusa I, Alsumali A, Garba AE, Regestein QR, Eguale T. Assessment of reported comparative effectiveness and safety of atypical antipsychotics in the treatment of behavioral and psychological symptoms of dementia: a network meta-analysis. JAMA Netw Open. 2019;2(3):e190828. In this recently published network meta-analysis, authors assessed the relative benefits and safety of atypical antipsychotics in the treatment of behavioral symptoms of dementia.
Cummings J, Mintzer J, Brodaty H, Sano M, Banerjee S, Devanand DP, et al. Agitation in cognitive disorders: international psychogeriatric association provisional consensus clinical and research definition. Int Psychogeriatrics. 2015;27(1):7–17.
Cohen-Mansfield J. Assessment of disruptive behavior/agitation in the elderly: function, methods, and difficulties. J Geriatr Psychiatry Neurol. 1995;8(1):52–60.
Griffiths AW, Albertyn CP, Burnley NL, Creese B, Walwyn R, Holloway I, et al. Validation of the Cohen-Mansfield agitation inventory observational (CMAI-O) tool. Int Psychogeriatrics. 2020;32(1):75–85.
Kales HC, Gitlin LN, Lyketsos CG. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. J Am Geriatr Soc. 2014;62(4):762–9.
Amjad H, Roth DL, Sheehan OC, Lyketsos CG, Wolff JL, Samus QM. Underdiagnosis of dementia: an observational study of patterns in diagnosis and awareness in US older adults. J Gen Intern Med. 2018;33(7):1131–8.
Cohen-Mansfield J, Billig N. Agitated behaviors in the elderly. I. a conceptual review. J Am Geriatr Soc. 1986 Oct;34(10):711–21.
Cohen-Mansfield J. Agitated behaviors in the elderly. II. Preliminary results in the cognitively deteriorated. J Am Geriatr Soc. 1986 Oct;34(10):722–7.
Finkel SI, Lyons JS, Anderson RL. Cohen-Mansfield agitation inventory in institutionalized elderly. Int J Geriatr Psychiatry. 1992;7(November 1991):4–7.
Kopecky HJ, Kopecky CR, Yudofsky SC. Reliability and validity of the overt agitation severity scale in adult psychiatric inpatients. Psychiatr Q. 1998;69(4):301–23.
Swift RH, Harrigan EP, Cappelleri JC, Kramer D, Chandler LP. Validation of the behavioural activity rating scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002;36(2):87–95.
De Medeiros K, Robert P, Gauthier S, Stella F, Politis A, Leoutsakos J, et al. The neuropsychiatric inventory-clinician rating scale (NPI-C): reliability and validity of a revised assessment of neuropsychiatric symptoms in dementia. Int Psychogeriatrics. 2010;22(6):984–94.
Nordstrom K, Zun LS, Wilson MP, Stiebel V, Ng AT, Bregman B, et al. Medical evaluation and triage of the agitated patient: consensus statement of the American association for emergency psychiatry project BETA medical evaluation workgroup. West J Emerg Med. 2012;13(1):3–10.
Geda YE, Schneider LS, Gitlin LN, Co-chair DSMN, Smith GS, Bell J, et al. Progress and anticipation of the future. Alzheimers Dement. 2014;9(5):602–8.
Lyketsos CG. Neuropsychiatric symptoms in dementia: overview and measurement challenges. J Prev Alzheimer’s Dis [Internet]. 2015;2(3):155–6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26779454%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4712963.
Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in older persons: advances in diagnosis and treatment. JAMA - J Am Med Assoc. 2017;318(12):1161–74.
Haigh EAP, Bogucki OE, Sigmon ST, Blazer DG. Depression among older adults: a 20-year update on five common myths and misconceptions. Am J Geriatr Psychiatry [Internet]. 2018;26(1):107–22. Available from: https://doi.org/10.1016/j.jagp.2017.06.011.
Sampson EL, White N, Lord K, Leurent B, Vickerstaff V, Scott S, et al. Pain, agitation, and behavioural problems in people with dementia admitted to general hospital wards: a longitudinal cohort study. Pain. 2015;156(4):675–83.
Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35(4):350–64.
Inouye SK. Delirium in hospitalized older patients: recognition and risk factors. J Geriatr Psychiatry Neurol. 1998;11(3):118–25.
Fong TG, Tulebaev SR, Inouye SK. Delirium in older adults: diagnosis, prevention, and treatment. B C Med J. 2017;59(3):165–70.
Golchin N, Frank SH, Vince A, Isham L, Meropol SB. Polypharmacy in the elderly. J Res Pharm Pract [Internet]. 2015;4(2):85–8 Available from: https://pubmed.ncbi.nlm.nih.gov/25984546.
Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol [Internet]. 2015/06/29. 2015 Aug;14(8):823–32. Available from: https://pubmed.ncbi.nlm.nih.gov/26139023
Reynish EL, Hapca SM, De Souza N, Cvoro V, Donnan PT, Guthrie B. Epidemiology and outcomes of people with dementia, delirium, and unspecified cognitive impairment in the general hospital: prospective cohort study of 10,014 admissions. BMC Med. 2017;15(1):1–12.
Hegeman AJM, Kok RM, Van Der Mast RC, Giltay EJ. Phenomenology of depression in older compared with younger adults: meta-analysis. Br J Psychiatry. 2012;200(4):275–81.
Chau DL, Walker V, Pai L, Cho LM. Opiates and elderly: use and side effects. Clin Interv Aging. 2008;3(2):273–8.
Adelman RD, Tmanova LL, Delgado D, Dion S, Lachs MS. Caregiver burden: a clinical review. JAMA - J Am Med Assoc. 2014;311(10):1052–9.
Kolanowski A, Boltz M, Galik E, Gitlin LN, Kales HC, Resnick B, et al. Determinants of behavioral and psychological symptoms of dementia: A scoping review of the evidence 2017;65(5):515–29.
Kim T, Jeong H, Won Han J, Kwak KP, Kim BJ, Kim SK, et al. Prevalence and risk factors of abusive behaviors in the caregivers of people with dementia in Korea. Psychiatry Investig. 2018;15(7):677–86.
Cooper C, Livingston G. Mental health/psychiatric issues in elder abuse and neglect. Clin Geriatr med [Internet]. 2014;30(4):839–50. Available from: https://doi.org/10.1016/j.cger.2014.08.011, 2014.
El Chakhtoura NG, Bonomo RA, Jump RLP. Influence of aging and environment on presentation of infection in older adults. Infect Dis Clin N Am. 2017 Dec;31(4):593–608.
Jesse S, Bråthen G, Ferrara M, Keindl M, Ben-Menachem E, Tanasescu R, et al. Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta Neurol Scand. 2017 Jan;135(1):4–16.
Campanelli CM, Fick DM, Semla T, Beizer J. Potentially inappropriate medication use in older adults: the American Geriatrics Society 2012 beers criteria. J Am Geriatr Soc. 2012;60(4):616–31.
Christodoulou CG, Fineti K, Douzenis A, Moussas G, Michopoulos I, Lykouras L. Transfers to psychiatry through the consultation-liaison psychiatry service: 11 years of experience. Ann General Psychiatry. 2008;7:1–7.
Ricotta DN, Parris JJ, Parris RS, Sontag DN, Mukamal KJ. The burden of guardianship: a matched cohort study. J Hosp Med. 2018 Sep;13(9):595–601.
Abraha I, Rimland JM, Trotta FM, Dell’Aquila G, Cruz-Jentoft A, Petrovic M, et al. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. the SENATOR-OnTop series. BMJ Open. 2017;7(3).
Brooker D. Dementia care mapping: A review of the research literature. Gerontologist. 2005;45(SPEC. ISS. 1):11–8.
Agens JE. Chemical and physical restraint use in the older person. Br J Med Pract. 2010;3(1).
Pan Y, Jiang Z, Yuan C, Wang L, Zhang J, Zhou J, et al. Influence of physical restraint on delirium of adult patients in ICU: a nested case-control study. J Clin Nurs. 2018 May;27(9–10):1950–7.
Wong AH, Taylor RA, Ray JM, Bernstein SL. Physical restraint use in adult patients presenting to a general emergency department. Ann Emerg Med. 2019 Feb;73(2):183–92.
Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. J Emerg Med. 2003 Feb;24(2):119–24.
Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S. Managing delirium and agitation in the older emergency department patient: the ADEPT tool. Ann Emerg med [Internet]. 2020;75(2):136–45. Available from: 10.1016/j.annemergmed.2019.07.023.
Frueh BC, Knapp RG, Cusack KJ, Grubaugh AL, Sauvageot JA, Cousins VC, et al. Patients’ reports of traumatic or harmful experiences within the psychiatric setting. Psychiatr Serv. 2005 Sep;56(9):1123–33.
Tarsy D, Baldessarini RJ, Tarazi FI. Effects of newer antipsychotics on extrapyramidal function. CNS Drugs. 2002;16(1):23–45.
Sahlberg M, Holm E, Gislason GH, Køber L, Torp-Pedersen C, Andersson C. Association of selected antipsychotic agents with major adverse cardiovascular events and noncardiovascular mortality in elderly persons. J Am Heart Assoc. 2015;4(9):1–11.
Leung JG, Benedetti AM, Frazee LA, Myers N. Comparison of short-acting intramuscular antipsychotic medication: impact on length of stay and cost. Am J Ther. 2011 Jul;18(4):300–4.
Zirker W, Dorokhine I, Knapp CM, Patel N, Musuku M. Haloperidol overdosing in the treatment of agitated hospitalized older people with delirium: a retrospective chart review from a community teaching hospital. Drugs Aging. 2013;30(8):639–44.
Devanand DP, Strickler JG, Huey ED, Crocco E, Forester BP, Husain MM, et al. Lithium treatment for agitation in Alzheimer’s disease (lit-AD): clinical rationale and study design. Contemp Clin trials [Internet]. 2018;71(march):33–9. Available from: https://doi.org/10.1016/j.cct.2018.05.019.
Tannenbaum C. Inappropriate benzodiazepine use in elderly patients and its reduction. J Psychiatry Neurosci. 2015;40(3):E27–8.
Morrison JR. Catatonia: Retarded and Excited Types. Arch Gen Psychiatry [Internet]. 1973 Jan 1;28(1):39–41. Available from: https://doi.org/10.1001/archpsyc.1973.01750310023005.
Mann SC, Caroff SN, Bleier HR, Welz WK, Kling MA, Hayashida M. Lethal catatonia. Am J Psychiatry. 1986 Nov;143(11):1374–81.
Rasmussen SA, Mazurek MF, Rosebush PI. Catatonia: our current understanding of its diagnosis, treatment and pathophysiology. World J psychiatry [Internet]. 2016 Dec 22;6(4):391–8 Available from: https://pubmed.ncbi.nlm.nih.gov/28078203.
Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on pharmacological Management of Alcohol Withdrawal. JAMA. 1997 Jul;278(2):144–51.
Sachdeva A, Choudhary M, Chandra M. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. J Clin Diagn Res [Internet]. 2015/09/01. 2015 Sep;9(9):VE01–7. Available from: https://pubmed.ncbi.nlm.nih.gov/26500991
van den Berg JF, Kruithof HC, Kok RM, Verwijk E, Spaans HP. Electroconvulsive therapy for agitation and aggression in dementia: a systematic review. Am J Geriatr Psychiatry [Internet]. 2018;26(4):419–34. Available from: https://doi.org/10.1016/j.jagp.2017.09.023.
Acharya D, Harper DG, Achtyes ED, Seiner SJ, Mahdasian JA, Nykamp LJ, et al. Safety and Utility of Acute Electroconvulsive 2016;30(3):265–73.
Kerner N, Prudic J. Current electroconvulsive therapy practice and research in the geriatric population. Neuropsychiatry (London). 2014;4(1):33–54.
Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, et al. Effect of citalopram on agitation in Alzheimer’s disease – the CitAD randomized controlled trial. Jama. 2014;311(7):682–91.
Ho T, Pollock BG, Mulsant BH, Schantz O, Devanand DP, Mintzer JE, et al. R- and S-citalopram concentrations have differential effects on neuropsychiatric scores in elders with dementia and agitation. Br J Clin Pharmacol. 2016;3:784–92.
Ehrhardt S, Porsteinsson AP, Munro CA, Rosenberg PB, Pollock BG, Devanand DP, et al. Escitalopram for agitation in Alzheimer’s disease (S-CitAD): methods and design of an investigator-initiated, randomized, controlled, multicenter clinical trial. Alzheimers Dement. 2019;15(11):1427–36.
Herrmann N, Ruthirakuhan M, Gallagher D, Verhoeff NPLG, Kiss A, Black SE, et al. Randomized placebo-controlled trial of Nabilone for agitation in Alzheimer’s disease. Am J Geriatr Psychiatry. 2019;27(11):1161–73.
Ballard CG, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev. 2006
Seitz DP, Adunuri N, Gill SS, Gruneir A, Herrmann N, Rochon P. Antidepressants for agitation and psychosis in dementia. Cochrane Database Syst Rev. 2011
van den Elsen GAH, Ahmed AIA, Verkes R-J, Kramers C, Feuth T, Rosenberg PB, et al. Tetrahydrocannabinol for neuropsychiatric symptoms in dementia: a randomized controlled trial. Neurology. 2015 Jun;84(23):2338–46.
Walther S, Mahlberg R, Eichmann U, Kunz D. Delta-9-tetrahydrocannabinol for nighttime agitation in severe dementia. Psychopharmacology. 2006;185(4):524–8.
Tampi RR, Joshi P, Marpuri P, Tampi DJ. Evidence for using dextromethorphan-quinidine for the treatment of agitation in dementia. World J Psychiatry. 2020;10(4):29–33.
Cummings JL, Lyketsos CG, Peskind ER, Porsteinsson AP, Mintzer JE, Scharre DW, et al. Effect of dextromethorphan-quinidine on agitation in patients with Alzheimer disease dementia a randomized clinical trial. JAMA - J Am Med Assoc. 2015;314(12):1242–54.
McDermott CL, Gruenewald DA. Pharmacologic Management of Agitation in patients with dementia. Curr Geriatr Reports. 2019;8(1):1–11.
Cummings J, Lai T-J, Hemrungrojn S, Mohandas E, Yun Kim S, Nair G, et al. Role of donepezil in the Management of Neuropsychiatric Symptoms in Alzheimer’s disease and dementia with Lewy bodies. CNS Neurosci Ther. 2016 Mar;22(3):159–66.
Cumbo E, Ligori LD. Differential effects of current specific treatments on behavioral and psychological symptoms in patients with Alzheimer’s disease: a 12-month, randomized, open-label trial. J Alzheimers Dis. 2014;39(3):477–85.
Gareri P, Putignano D, Castagna A, Cotroneo AM, De Palo G, Fabbo A, et al. Retrospective study on the benefits of combined Memantine and cholinEsterase inhibitor treatMent in AGEd patients affected with Alzheimer’s disease: the MEMAGE study. J Alzheimers Dis. 2014;41(2):633–40.
Davies SJC, Burhan AM, Kim D, Gerretsen P, Graff-Guerrero A, Woo VL, et al. Sequential drug treatment algorithm for agitation and aggression in Alzheimer’s and mixed dementia. J Psychopharmacol. 2018;32(5):509–23.
Maguire GA. Impact of antipsychotics on geriatric patients: efficacy, dosing, and compliance. Prim Care Companion J Clin Psychiatry. 2000 Oct;2(5):165–72.
Walaszek A. Behavioral and psychological symptoms of dementia. Washington: American Psychiatric Association Publishing; 2019.
Jacobson SA. Clinical manual of geriatric psychopharmacology. 2nd ed. Arlington: American Psychiatric Publishing; 2014.
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Geriatric Psychiatry
Rights and permissions
About this article
Cite this article
Subramanian, S., Fahed, M., Dix, E. et al. Emergent and Non-Emergent Agitation in the Older Adult: Evaluation and Management. Curr Geri Rep 10, 73–81 (2021). https://doi.org/10.1007/s13670-021-00358-6
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13670-021-00358-6