NUR 7633 Module 3 Dementia Agitation Case: DICE Approach, Antipsychotic Risk and Citalopram Example

Shouting at Six O'Clock: Describing, Investigating and Treating Agitation in an 86-Year-Old Man With Alzheimer Disease

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7633: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Population, Part A

Mentor Name

Month Day, Year

Shouting at Six O'Clock: Describing, Investigating and Treating Agitation in an 86-Year-Old Man With Alzheimer Disease

The Request

Frank, an invented patient, is 86 and has lived in an assisted living home in Vineland for two years. He repaired buses for the county for thirty-five years. His Alzheimer disease was diagnosed six years ago, and his last cognitive test, a year ago, scored 14 out of 30. Over the past six weeks he has begun shouting and swinging his arms at aides during his evening bath and when they help him into pajamas, and last week he scratched an aide's arm. The home's nurse asks for a medicine to calm him and says the family is worried he will be asked to leave.

He takes donepezil, a low dose of a blood pressure medicine and a stool softener. He wears dentures and a hearing aid in his right ear. His son visits on Sundays and says his father was always a private man who showered in the morning before work.

The home's concern about discharge is taken seriously, because losing his place would mean a move to an unfamiliar nursing home, which often worsens agitation. The administrator agrees to hold any decision for four weeks while the plan is tried. The aide who was scratched is asked how she is, and her account of the incident, which happened when she lifted his left arm into a sleeve, becomes one of the most useful clues in the case.

Describing the Behavior

Kales et al. (2015) described a structured approach for behavioral and psychological symptoms of dementia, called describe, investigate, create and evaluate. Caregivers first describe the behavior closely, including when it happens, with whom and what came before and after. Clinicians then investigate causes in the person, the caregiver and the setting, such as pain, infection, medicines, sensory loss, poor sleep, communication style and a noisy or rushed environment. The team creates a plan with the caregiver and evaluates whether it worked. The authors advise nonpharmacologic steps first, with caregiver interventions carrying the strongest evidence, and note that antipsychotics, though the best-studied drugs, carry a concerning balance of risk and benefit.

A two-week behavior log is kept by the evening aides. It shows the outbursts happen only during evening bathing and undressing, never at meals or during his son's visits. They are worse with a new aide who works quickly and speaks from behind him on his deaf side, and they began after the home moved baths from mornings to evenings to fit a new staffing schedule.

Investigating the Causes

Several causes come forward. The change in bath time took away a routine he kept for sixty years. He is approached on his deaf side by someone he does not know. He winces when his left shoulder is moved, and an examination finds a painful, stiff shoulder he cannot describe in words. His sleep log shows he dozes most of the afternoon and wakes at night, which leaves him tired and irritable at bath time. A urine test is negative, and there is no sign of constipation or delirium.

Creating the Plan

The home restores his morning shower, scheduled with the same aide each day where possible. Aides approach from his right side, say his name, explain each step and give him the washcloth to use himself. Scheduled acetaminophen three times a day treats the shoulder, and physical therapy is arranged. An afternoon activity, sorting nuts and bolts in a toolbox his son brings in, replaces the long nap. His son records a short message the aides can play when he is upset. The aides receive a brief training on approaching people with dementia who resist care.

Weighing Medicines

Schneider et al. (2005) combined fifteen trials, nine of them never published, that compared newer antipsychotics with placebo in dementia, including 3,353 people given the drugs and 1,757 given placebo for mostly 10 to 12 weeks. Death occurred in 3.5 percent of those on the drugs compared with 2.3 percent on placebo, an odds ratio of 1.54. The risk was similar across the drugs studied, which led to warnings on all of them. For Frank, this means an antipsychotic would be considered only if he were in danger or had psychosis causing severe distress, after care changes had been tried, at the lowest dose and with a plan to stop.

Porsteinsson et al. (2014) randomly assigned 186 people with Alzheimer disease and agitation at eight centers to citalopram, raised toward 30 mg a day, or placebo, with both groups also receiving a psychosocial intervention for nine weeks. Citalopram improved agitation scores and caregiver distress more than placebo, and 40 percent of patients on citalopram were rated moderately or markedly improved compared with 26 percent on placebo. But thinking scores worsened slightly and the QT interval lengthened by about 18 milliseconds, which matters because the dose used is now above the limit recommended for people over 60.

For Frank, no medicine is started now. If the outbursts continue after four weeks of the new plan, citalopram at a low dose, with an electrocardiogram before and after starting, would be the first medicine discussed with his son, who holds his health care proxy.

Evaluating the Plan

The aides continue the behavior log for four weeks. The goal is fewer than one outburst a week and no injuries to staff. His pain is checked with an observational pain scale designed for people who cannot report pain, and his sleep log is reviewed. His son is asked at each Sunday visit how his father seems.

Conclusion

Frank's evening agitation has clear causes found through careful description: a changed routine, approach on his deaf side, shoulder pain, daytime sleep and rushed care. A plan built with the aides and his son restores his morning shower, treats his pain and changes how care is given. Antipsychotics are held back because of the higher death rate in pooled trials, and citalopram is kept in reserve with an electrocardiogram if needed. The behavior log, a pain scale and the son's observations will show whether the plan works.

References

Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. BMJ, 350, Article h369. https://doi.org/10.1136/bmj.h369

Porsteinsson, A. P., Drye, L. T., Pollock, B. G., Devanand, D. P., Frangakis, C., Ismail, Z., Marano, C., Meinert, C. L., Mintzer, J. E., Munro, C. A., Pelton, G., Rabins, P. V., Rosenberg, P. B., Schneider, L. S., Shade, D. M., Weintraub, D., Yesavage, J., & Lyketsos, C. G. (2014). Effect of citalopram on agitation in Alzheimer disease: The CitAD randomized clinical trial. JAMA, 311(7), 682-691. https://doi.org/10.1001/jama.2014.93

Schneider, L. S., Dagerman, K. S., & Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. JAMA, 294(15), 1934-1943. https://doi.org/10.1001/jama.294.15.1934