This webinar helps physicians conduct a systematic evaluation for behavioral changes in persons with dementia. It offers approaches for developing a comprehensive care plan for disruptive behaviors.

1. Assessment and
Management of Disruptive
Behaviors in Persons
with Dementia

2. CME Provider Information
• Satisfactory Completion
• Learners must complete an evaluation form to receive a certificate of completion. You must
participate in the entire activity as partial credit is not available. If you are seeking continuing
education credit for
a specialty not listed below, it is your responsibility to contact your licensing/certification board to
determine course eligibility for your licensing/certification requirement.
• Physicians
• In support of improving patient care, this activity has been planned and implemented by Amedco
LLC and VITAS® Healthcare, Marketing Division. Amedco LLC is jointly accredited by the
Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for
Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide
continuing education for the healthcare team.
• Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA
PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent
of their participation in the activity.

3. CE Provider Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board
of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health
Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists
through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number:
139000207/RT CE Provider Number: 195000028/Approved by the Illinois Division of Profession Regulation for: Licensed Nursing
Home Administrators and Illinois Respiratory Care Practitioners.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards
(ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE
providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be
accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval
period: 06/06/2021 – 06/06/2024. Social workers completing this course receive 1.0 continuing education credit(s).VITAS
Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of
Registered Nursing, Provider Number 10517, expiring 01/31/2023.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs,
OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE
Credit in Illinois.

4. Objectives
• Describe the occurrence and impact of dementia-related behaviors
• Construct a systematic evaluation for behavioral changes in
persons with dementia
• Develop a comprehensive care plan that incorporates caregiver
education and non-pharmacologic interventions followed by
pharmacologic management for disruptive behaviors

5. Most Common Etiologies of Dementia
Alzheimer's Association. (2021). 2021 Alzheimer’s Disease Facts and Figures. Retrieved from
https://www.alz.org/media/ Documents/alzheimers-facts-and-figures.pdf
Cause Prevalence Pathophysiology
Alzheimer’s disease 60-80% Amyloid plaques and
neurofibrillary tangles
Mixed pathologies >50%
Cerebrovascular
disease
5-10% More than one
neuropathology
Lewy Body disease 5% Alpha-synuclein protein
Frontal Lobar
Degeneration
3% Tau protein

6. Epidemiology
• 2021 US Alzheimer’s estimate:
– 6.2 million people aged 65+
– 2/3 are women, ~ 1 in 3 women
develop dementia in their lifetime
• More than 1 in 9 persons over
the age of 65 have dementia
• 1 in 3 persons over the age of
65 dies with dementia
• Diagnosis of dementia cuts
one’s life expectancy in half
• Dementia is the fifth-leading
cause of death in persons
over 65
• Between 2000-2019,
dementia-related deaths
increased 145%
Alzheimer's Association. (2021). 2021 Alzheimer’s Disease Facts and Figures. Retrieved from
https://www.alz.org/media/ Documents/alzheimers-facts-and-figures.pdf

7. Natural History of Dementia
ADL
Dependency
Death
Low
Time (Slow decline)
High
Hospice Eligible
FAST 7a or 7C plus
Disease related complication
within the last several months
Disease-related
complications include,
but are not limited to:
• UTI
• Sepsis
• Febrile episode
• Delirium
• Pneumonia
• Hip fracture
• Eating difficulty
or dysphagia
• Dehydration
• Feeding tube

8. 78 y/o with rapidly progressive
Alzheimer’s and vascular dementia
after sustaining a fall at home with a hip
fracture that was surgically repaired.
During the patient’s skilled stay, the
patient has become mostly WC and/or
bedbound and not participating in PT
with both physical and verbal agitation and
aggression, especially when trying to
engage in activities or move the patient.
The agitation is new since the hip fracture.
The psychiatrist diagnosed the patient
with depression and prescribed sertraline
50mg followed by valproic acid 250mg
BID due to refractory symptoms.
The patient has been more lethargic
but remains agitated at times. Additional
changes include 5% weight loss in 1 month
due to a poor appetite, functional decline
with a PPS decrease from 80 to 40, and
dependency in 3/6 ADLs from 1/6 prior
to the fall.
After completion of skilled care, the patient
was transitioned to long term care. The
daughter expresses guilt as she recognizes
her mom is upset and angry because she
never wanted to be in a nursing home.
Case

9. Delirium
Acute Onset and
Fluctuating Course
AND Inattention
plus either
Disorganized
Thinking
Altered LOC
DELIRIUM

10. Terminal Restlessness
THE USUAL ROAD
THE DIFFICULT
ROAD

11. Dementia Behaviors
Thought and Perceptual
Disturbances
• Delusions
• Paranoia
• Hallucination
Mood Disturbances
• Anxiety
• Depression
• Irritability
Activity Disturbance
• Agitation and/or aggression
• Wandering
• Purposeless hyperactivity
• Apathy
• Impulsivity
• Socially inappropriate behavior
• Sleep problems
• Repetitive behavior

12. Agitation/Aggression Definition
International Psychogeriatric Association convened a panel of experts
with the goal of establishing principles guiding the definition of agitation
in elderly populations:
1. Occurring in patients with cognitive
impairment or a dementia syndrome;
2. Exhibiting behavior consistent with
emotional distress;
3. Manifesting excessive motor
activity, verbal aggression, or
physical aggression; and
4. Evidencing behaviors that cause
excess disability and are not
solely attributable to another
disorder (psychiatric, medical,
or substance-related)

13. Neuropsychiatric Symptoms (NPS)
by Stage of Dementia
Radue, et al. (2019). Neuropsychiatric symptoms in dementia. Handbook of Clinical Neurology, 167, 437-454.
4.3%
11.2% 15.2%
44.3%
38.2%
13.3%
32.6%
30.3%
30.0%
31.4%
82.3%
56.0% 54.5%
25.7% 30.4%
Normal
cognition
Mild cognitive
impairment
Mild dementia Moderate
dementia
Severe
dementia
No symptoms 1-2 symptoms 3+ symptoms
7%
16%
17%
31%
32%
34%
36%
39%
39%
40%
42%
49%
0% 10% 20% 30% 40% 50% 60%
Euphoria
Hallucinations
Disinhibition
Delusions
Aberant motor behavior
Appetite disorder
Irrtability
Sleep Disorder
Anxiety
Aggression
Depression
Apathy

14. Symptom Experience in Persons With
Dementia in the Last Year of Life
Mitchell, et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine (361), 1529-1538.
0
5
10
15
20
25
30
35
40
Dyspnea Pain Pressure ulcers Aspiration Agitation
Residents
With
Symptoms
(%)
Distressing Symptoms
Months Before Death (no. of residents alive during interval)
>9-12 (N=67) >6-9 (N=96) >3-6 (N=128) 0-3 (N=177)

15. DICE
Describe the behavior
Investigate the underlying contributors/causes
Create intervention: non-pharmacologic and
pharmacologic
Evaluate the interventions effectiveness

16. O’Gorman, et al. (2020). A framework for developing pharmacotherapy for agitation in Alzheimer’s disease:
recommendations of the ISCTM working group. The Journal of Prevention of Alzheimer's Disease, 7(4), 274-282.
Behavior Description
• Characterization
• Severity or quantification
• Temporal onset and course
Scale Measure
Cohen-Mansfield Agitation Inventory 4 behavioral categories, 29 total items, caregiver response over last 2 weeks,
behavior frequency ranges from 1 to 7, higher scores more behaviors
Neuropsychiatric inventory 10 or 12 (sleep and appetite added) behaviors rated by frequency
(4 categories) severity (3 categories), caregiver distress (5 categories)
over a week, higher scores more behavioral burden
Behavioral pathology in
Alzheimer’s disease
7 behavioral categories containing 25 symptoms, each scored
on a 4-point severity scale ascertained by a caregiver
• Context of personal,
family, social, and
medical history
• Associated circumstances,
including precipitants and
alleviating factors
• Caregiver status

17. Impact of Disruptive Behaviors
in Dementia
Patient
• Increased morbidity (cognitive/
functional); lower quality of life
• Abuse and neglect
• Increased likelihood of
hospitalization with a longer
length of stay
• Nursing home placement
• Increased mortality
Caregiver
• Increased burden,
stress, and strain
• Sleep disturbances,
depression, and anxiety
• Lower quality of life
• Reduced income
from employment
• Increased mortality

18. Case (cont.)
Describe the behavior and rationale to treat
– Agitation and aggression worse with
movement and activity, new after fall
– Verbal (yelling when trying to move or
interact) and physical (resistive to daily
care and strike out when try to move)
– Intermittent sleeping and agitation and
daughter reports a poor quality of life
– Unsteady on feet, not
wanting to move a
round much
– Decreased oral intake
– Potential risk to staff
for physical harm

19. DICE
• Describe the behavior
• Investigate the underlying
contributors/causes
• Create intervention: non-pharmacologic and
pharmacologic
• Evaluate the interventions effectiveness

20. Contributors to Agitation and Restlessness
Ringman JM, Schneider L. (2019) Treatment Options for Agitation in Dementia. In Current Treatment Options Neurology (Vol 21, 30).
Contributor Causes Approach
Physical symptom Pain, SOB, constipation Opioid or laxative
Psychological symptom
Depression, anxiety,
delusions, hallucinations
SSRI, SNRI,
antipsychotic
Medical condition
Infection, COPD, HF, gout, hyperglycemia,
electrolyte disturbance, constipation, insomnia
Treat condition
Unmet need Hunger, thirst, hot, cold Attend to need
Sensory impairment Poor vision/hearing Adaptive
Environment
Under/over stimulation, change in
routine, life stressor, pt-cg relationship
Modify
Pharmacologic Anticholinergic drug, digitalis, benzodiazepine Discontinue

21. Contributors to Agitation and Restlessness
Huesbo B, Ballard C, Sandvik R, et al.(2011) Efficacy of treating pain to reduce behavioural disturbances
in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ Vol. 343.
Atee M, Morris T, Macfarlane S et al. (2021) Pain in Dementia: Prevalence and Association
with Neuropsychiatric Behaviors. J Pain Symptom Manage Vol 61, p 1215-1226.
Step Treatment Study Treatment
1 APAP Maximum dose 3gm
2 Morphine 5mg Twice daily
3 Buprenorphine
5mcg patch, can
increase to 10mcg
4 Pregabalin
25mg up to
300mg daily

22. Case (cont.)
Investigate
• Additional PMH patient grimaces with
movement and braces on the side with the
hip fracture repair. The patient is not taking
the as-needed acetaminophen and has no
other analgesic ordered. Staff report the
patient seems to alternate between
agitation and over-sedation and is
otherwise withdrawn. Appetite is poor but
has no apparent nausea or constipation.
Insomnia with difficulty falling asleep and
early morning awakenings.
• Patient’s other chronic medical conditions
are well controlled. The patient does not
have altercations with staff or her roommate
unless trying to be moved. Her daughter
reports mom misses her dog and home.
Besides the sertraline and valproic acid,
no changes in medications.
• Physical exam: temporal wasting, hearing
and vision seem intact, pain behaviors as
described especially with ROM of repaired
hip, and bloodwork is unremarkable.
Considerations
• Pain from hip
fracture repair
• Depression
• Loneliness
• Medication

23. DICE
• Describe the behavior
• Investigate the underlying
contributors/causes
• Create intervention: non-pharmacologic
and pharmacologic
• Evaluate the intervention’s effectiveness

24. • Caregiver
– Learning and behavioral (ABC)
– Antecedent to behavior behavior
consequence reinforces behavior
• Environment
– Environmental vulnerability and reduced
stress thresholds: a mismatch between
the setting and the patient’s ability to
deal with it
Ayalon, et al. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric
symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188.
• Person with dementia
– Unmet need: behavior as
an underlying need
– Agitation etiology culmination
from present abilities, level of
cognition and function, and
past/present interests with
physical, psychological,
social, and spiritual needs
Dementia Behavior Models

25. Non-Pharmacologic: Persons
With Dementia
Watt JA et al. Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia:
A Systematic Review and Network Meta-analysis. Ann Intern Med 2019;171:633-642
Treatment Studies (N)
Network
Meta-analysis
Meta-analysis
Standardized Mean
Difference
CMAI Re-expressed
as mean difference
on CMAI
Massage and Touch 6 (385) -0.75 (-1.12,-0.38) -0.90 (-1.28,-0.518) -10.67
Multidisciplinary
Care Plan
4 (552) -0.50 (-0.99,-0.01) -0.44 (-1.0,0.12) -7.11
Music +
Massage/Touch
1 (34) -0.91 (-1.75,-0.07) -1.71 (-2.36,-1.05) -12.94
Recreational Therapy 8 (474) - 0.29 (-0.57,-0.01) -0.26 (-0.64,0.12) -4.12
25
Bold text indicates treatment efficacy across all types of agitation and/or aggression, clinically important
difference 5.69 (aggression) and 7.11 (agitation)

26. Non-Pharmacologic: Persons
With Dementia
Leng, et al. (2020). Comparative efficacy of non-pharmacological interventions on agitation in people with dementia:
A systematic review and Bayesian network meta-analysis. International Journal of Nursing Studies, 102, 103489.
Treatment
Standardized
Mean Difference
Massage −5.22 ( −8.21,−2.49)
Light Therapy −5.25 (−9.90,−0.61)
Music Therapy −3.61 (−7.29, −0.23)
Reminiscence Therapy −4.59 (−8.97 to −0.51)
Animal-Assisted Intervention −3.14 (−5.89 to −0.46)
Personally Tailored Intervention −2.98 (−5.18 to −0.85)
For network meta-analysis,
demonstrated the following
rank probability:
– Massage therapy - 1
(43%)
– Animal-assisted
intervention - 2 (16%)
– Personally tailored
intervention - 3 (18%)
– Pet robot intervention -
4 (11%)

27. Hughes, et al. (2017). Research on supportive approaches for family and other caregivers.
Research summit on dementia care: Building evidence for services and supports.
Non-Pharmacologic:
Caregiver Interventions
• Elements of caregiver support
– Education and skills training
(conflict avoidance, support
ADL, and communication skills)
– Care coordination
– Counseling and support groups
– Respite
• Example Programs
– REACH II and REACH VA
– The Tailored Activity Program (TAP) -
Occupational Therapy and Skills2Care
– Savvy Caregiver
– New York University
Caregiver Intervention
• A meta-analysis of 23 randomized clinical
trials, involving almost 3,300 community-
dwelling patients and their caregivers
– Significantly reduced behavioral symptoms
(effect size 0.34, p<0.01) and negative
caregiver reaction (effect size 0.15, p<0.006)
– Similar to antipsychotics for behavior and
cholinesterase inhibitors for memory

28. Responses to
Non-Pharmacologic Interventions
Greater Response
• Higher levels of cognitive function
• Fewer difficulties with ADLs
• Speech
• Communication
• Responsiveness
Less Response
• Staff barriers (refuse to participate)
• Patient in pain

29. Case (cont.)
Describe behavior and rationale
to treat
• Agitation and aggression worse
with movement and activities
• Risk to patient and staff
Investigate
• Pain
• Depression and anxiety
• Loneliness
• Medication
Create: Non-pharmacologic
• Initiate animal-assisted intervention
as patient misses her dog
• Recreational therapy tailored to
the patient’s needs
• Consider what additional services
hospice could offer
• Pain: APAP 1,000mg every 8 hours,
morphine 5mg prior to bathing and
at night and prn. Bowel regimen
• Medication: Wean off valproic
acid and optimize depression treatment

30. Dementia Behaviors and
Pharmacologic Treatment
Helpful
• Psychosis
– Delusions
– Hallucinations
– Paranoia
• Depression, anxiety, and irritability
• Agitation and aggression
Not Helpful
• Day/night reversal
• Calling out
• Repetitive
behaviors
• Apathy
• Resistive to care
• Wandering

31. Therapeutic Class Trial Side Effects
Trazodone + RTC Sedation, hypotension
SSRI (citalopram) + RCT Nausea, diarrhea, QTc inc >20mg daily
Antipsychotics + RCT Stroke, infection, seizure, QTc inc, DM, death
Lorazepam + RCT Sedation, falls, ataxia, agitation
Dextromethorphan/quinidine + RCT Falls, dizziness, diarrhea, UTIs
Carbamazepine
Valproic acid
- RCT
- RCT
Sedation, anemia, liver toxicity, sedation
NMDA antagonist - RCT/+obs Constipation, dizziness
ACheI - /+RCT/+obs Nausea, dizziness, weight loss
Cannabinoids - RCT Low dose used, oral form
Pharmacologic Treatment of Agitation
Radue, et al. (2019). Neuropsychiatric symptoms in dementia. Handbook of Clinical Neurology, 167, 437-454.
Ringman, J. et al. (2019). Treatment options for agitation in dementia. Current Treatment Options in Neurology, 21(7), 1-14.

32. Trazadone
• Several small randomized
controlled trials indicate benefit
– Cochrane review
inconclusive evidence
• Dosing:
– 25-100mg BID-TID and q 2hrs
prn, maximum dose 300mg daily
(150mg in frail older adults)
• Adverse effects:
– Orthostasis, syncope,
hypotension, dizziness
– Priapism
– SIADH
– Somnolence
– QTc prolongation

33. Dementia Related Agitation and Citalopram
Antonsdottir, et al. (2015). Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinion on Pharmacotherapy, 16(11), 1649-1656.
Neurobehavioral Rating Scale (NBRS) - Agitation Subscale
No. of participants
Citalopram 94 87 85 86
Placebo 92 84 84 81

34. Citalopram Considerations
• Starting dose 10mg, up to 40mg daily
• QTc prolongation, which is dose-dependent
above does of 20mg
• Confusion increased at doses of 30mg
daily or higher
• Consider 2x daily dosing
– 10mg daily for 2 weeks
– 10mg 2x daily thereafter
• Other SSRI side effects
• Onset of action within a week in one study

35. Antipsychotics
• Most-studied pharmacologic intervention
for dementia-related agitation
• Moderate efficacy across trials and agents
(18% respond above placebo response)
– Typical antipsychotics
– Atypical antipsychotics
• Substantial side effects
• Black box warning: cerebrovascular
events and death (1% difference)
• Lowest dose possible for the shortest
duration feasible

36. Antipsychotics (Cont.)
Antipsychotic
Recommended
Dose
Formulations Frequency Characteristics
Risperidone 0.5-2.0mg Tab, liquid, IM 2x daily
Extrapyramidal
symptoms
Olanzapine 2.5-15mg tab Daily Wt gain, inc sugar
Quetaipine 25-400mg tab
3x daily (unless
ER)
Sedating, least
extrapyramidal
Aripiprazole 5-30mg Tab, liquid, IM Daily Less QT
Haloperidol 0.5-5mg
Tab, liquid,
IM, IV, sub q
2-4x daily
Chlorpromazine 10-200mg
Tab, liquid,
IV, rectal
2-3x
daily
Very sedating

37. CATIE-AD
Schneider, L. S., et al. (2008) Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease.
The New England Journal of Medicine; 355(15), 1525-1538.
Greatest benefits in persons demonstrating anger, aggression, and paranoia

38. Relapse Risk With
Antipsychotic Discontinuation
Devanand, et al. (2012). Relapse risk after discontinuation of risperidone in Alzheimer's disease. New England Journal of Medicine, 367(16), 1497-1507.
Severe baseline symptoms at initiation, increases likelihood of worsening symptoms with discontinuation

39. Watt, et al. (2019). Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network meta-analysis. Annals of Internal Medicine, 171(9), 633-642.
Antipsychotic Summary
• Modest efficacy for treatment
of agitation and aggression
in dementia
• Studies usually short
duration: 6 to 12 week
• Large placebo effect: 30%
or higher on average
• No difference in efficacy
between typical and
atypical antipsychotics
• Typical antipsychotics greater
side effects
– Somnolence, urinary tract
infection, incontinence
– Extrapyramidal symptoms and
abnormal gait and falls
– Anticholinergic effects, postural
hypotension, prolonged QT
– Weight gain, diabetes, and
metabolic syndrome
– Cognitive worsening; seizures
– Stroke (NNH 99) and death (NNH 47)

40. FDA-Approved Medications for
Alzheimer’s Disease
*Cholinesterase inhibitors: Nausea, vomiting, diarrhea, dizziness, and agitation
Medication Severity Dose Side Effects
Donepezil (Aricept) Mild to severe 5-10mg; 23mg *Nightmares
Rivastigmine (Exelon) Mild to moderate
4.6 & 9.5mg
(13mg) patch
*Weight loss
Galantamine (Razadyne) Mild to moderate 8-24mg *
Memantine (Namenda XR) Moderate to severe 28mg QD
Constipation,
dizziness, HA
Rivastigmine improves apathy, anxiety, delusions, and hallucinations in LBD
All cholinesterase inhibitors may delay onset/reduce behavioral symptoms in Alzheimer’s/LBD

41. Benzodiazepines
• Binds to GABA receptor in CNS
• Anxiolytic, sedative, and hypnotic
effects (anterograde memory)
• Some evidence lorazepam and
alprazolam to reduce agitation
• Increased risk of adverse events
– Cognitive impairment/
confusion/delirium
– Falls
– Hip fracture
– Sedation
– Paradoxical agitation
Benzodiazepine Half-life Dosage range
Diazepam
20-50 hours
Over 100 OA
2-10mg
2-4x day
Lorazepam 12 hours
0.5-2mg
2-3x day
Alprazolam
16 hours
(9-27 range)
0.25-3mg
2-4x day
Clonazepam 30-40 hours
0.25-5mg
2-3x day

42. Pimavanserine
• 5-HT2A antagonist indicated for hallucinations and
delusions associated with Parkinson’s disease
• Three trials for agitation or psychosis in dementia,
all of which were essentially negative
• Black box warning for increased mortality in
dementia and is associated with QT prolongation,
peripheral edema, and confusion

43. Cummings, et al. (2015) Effect of dextromethorphan-quinidine on agitation in persons with
Alzheimer’s disease dementia. A randomized clinical trial. JAMA vol 314(12), 1242-54.
Dextromethorphan-Quinidine for Dementia
Agitation in Alzheimer’s Disease
• FDA approved for the treatment
of pseudobulbar affect
• Modulates glutamate,
serotonin, and norepinephrine
• Only one randomized controlled
trial to date for agitation
• Side effects include
– Falls
– UTIs
– Diarrhea
– Dizziness
• QTc prolongation

44. Phenobarbital
• No data available
• Many clinicians, health
systems, and long-term care
facilities leverage its use
• 30 to 120mg TID and q2 prn
• Adverse Reactions
– Respiratory depression
– Stevens-Johnsons
– Anemia, TTP, and blood
dyscrasias
– Withdrawal symptoms with
abrupt withdrawal
– Lethargy and drowsiness
– Nausea, vomiting, and hepatitis

45. DICE
• Describe the behavior
• Investigate the underlying
contributors/causes
• Create intervention: non-pharmacologic and
pharmacologic
• Evaluate the interventions effectiveness

46. Case (cont.)
Describe behavior and
rationale to treat
• Agitation and aggression worse
with movement and activities
• Risk to patient and staff
Investigate
• Pain
• Depression and anxiety
• Loneliness
• Medication
Create
Contributors APAP 1,000mg
every 8 hours, morphine 5mg every
8 hours, plus bowel regimen; stop
sertraline and initiate citalopram
Non-pharmacologic Animal-assisted
intervention/recreational therapy
Pharmacologic Citalopram and
wean off valproic acid; trazadone
25mg as needed

47. Case (Cont.)
Describe behavior and
rationale to treat
• Agitation and aggression worse
with movement and activities.
• Risk to patient and staff
Investigate
• Pain
• Depression and anxiety
• Loneliness
• Medication
Create
Contributors APAP 1,000mg
every 8 hours, morphine 5mg every
8 hours plus bowel regiment;
Citalopram 10mg twice daily
Non-pharmacologic Animal assisted
intervention/recreational therapy
Pharmacologic Citalopram 10mg
twice daily, off valproic acid;
trazadone 50mg nightly and
able to discontinue as needed

48. References
Al Ghassani, et al. (2021). Agitation in people with dementia: A concept analysis. Nursing Forum, 56(4), 1015-1023).
Alzheimer's Association. (2021). 2021 Alzheimer’s Disease Facts and Figures. Retrieved from https://www.alz.org/
media/Documents/alzheimers-facts-and-figures.pdf
Antonsdottir, et al. (2015) Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinion
on Pharmacotherapy, vol 16(11), 1649-1656.
Gaugler, et al. (2021). Alzheimer’s Association. 2021 Alzheimer’s Disease Facts and Figures. Alzheimer’s Dementia:
Chicago, IL, USA, 17.
Atee et al. (2021) Pain in Dementia: Prevalence and Association with Neuropsychiatric Behaviors. Journal of Pain
Symptom Manage Vol 61, p 1215-1226.
Ayalon, et al. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric
symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188.
Ballard, C. et al. (2009). Management of agitation and aggression associated with Alzheimer disease. Nature Reviews
Neurology, 5(5), 245-255.
Cohen-Mansfield, et al. (2014). Predictors of the impact of nonpharmacologic interventions for agitation in nursing
home residents with advanced dementia. The Journal of Clinical Psychiatry, 75(7), 15076.
Cummings, J. (2015). Effect of dextromethorphan-quinidine on agitation in patients with Alzheimer disease dementia:
a randomized clinical trial. JAMA, 314(12), 1242-1254.

49. References
Devanand, et al. (2012). Relapse risk after discontinuation of risperidone in Alzheimer's disease. New England
Journal of Medicine, 367(16), 1497-1507.
Husebo, et al. (2011). Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes
with dementia: cluster randomised clinical trial. BMJ, 343.
Hughes, et al. (2017). Research on supportive approaches for family and other caregivers. Research summit on
dementia care: Building evidence for services and supports.
Leng, et al. (2020). Comparative efficacy of non-pharmacological interventions on agitation in people with dementia:
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