Geri0402_33-40_cme, exam

The Brain
Series editors: Jesse Weinberger, MD,and Deborah B. Marin, MD Agitation
How to manage behavior disturbances
in the older patient with dementia
Judith Neugroschl, MD
Behavior disturbances are common among persons with dementia and can be clinically challenging to manage. Delusions and hallucinations, aggression and combativeness, sleep disorders, anxiety, and depression—collectively characterized as agitation—are among the commonly occurring behavioral problems affecting persons with dementia. Agitation can be precipitated by undiagnosed medical problems or pain, drug interactions, environmental or social triggers (unpleasant experiences, overstimulation, unwanted care), poor sleep, delirium, and depression. Effective management involves behavioral assessment and pharmacotherapy with antipsychotics (neuroleptics), antidepressants, and mood stabilizers.
synaptic receptor sensitivity.4 Studiesusing functional neuroimaging suggest Neugroschl J. Agitation: How to manage behavior disturbances in the older patient withdementia. Geriatrics 2002; 57(April):33-37.
that frontal and temporal lobe pathol-ogy is associated with agitation andparticularly psychosis.5 In addition,psychosis has been associated with sig-nificantly increased amounts of amy- Bmon in older persons with de- behavior disturbance in dementia.Two increased amounts ofneurofibrillary forms (table 1) and are often collectively or substance intoxication or withdrawal.
resistance to care, and self-injury. In gen- eral, agitation that occurs in response to distress for patients and their caregivers.
cine, New York, NY. She has no realor apparent conflicts of interest relat- April 2002 Volume 57, Number 4 Geriatrics
CME Geriatrics
Table 1 Behavior disturbances (agitation) * Packing, opening/closing drawers, hoarding Psychotic symptoms. Delusions and hal-
† Combative behavior during bathing and dressing) Source: Prepared for Geriatrics by Judith Neugroschl, MD stage dementia.8 Prevalence of psychoticsymptoms in persons with dementia isapproximately 19% for delusions and standing orders for analgesic therapy.
● Patients with an exacerbation of and creatinine), and a complete blood proximately 40% of all delusions. The count to rule out infection or anemia.
any of which can result in agitation.
hiding or stealing personal belongings.
● Changes in renal or hepatic func- been ruled out, assess the scope, in- are in a residence other than their believe that a deceased relative is alive bances and also should be considered.
● the duration, frequency, and event that has “just happened” but that ● the pattern of the disturbance (eg, see a person on television and think that it is a friend or relative or that the ● and which activities and caregivers person is actually in the room.
typically precipitate agitation episodes.
Disturbance of activity. Disturbance of
Patient assessment. In the case of
efficacy of interventions. Caregivers can Aggression. Aggressive behavior is
sus guidelines for treatment of agitation actions, particularly in patients recently Geriatrics April 2002 Volume 57, Number 4
Table 2 Common triggers of behavior disturbances in persons care, verbal outbursts, and physicalcombativeness. Aggression may be Inability to channel energies constructively tasks or engage in various activities, or Frustration at not being able to complete tasks Anxiety about being bathed, dressed, toileted Response to caregiver’s anger, frustration, or fear Response to recent stressor (eg, death of a loved one) Noise; change in routine; lack of structure throughout day Sleep disturbance. Fragmented sleep
Source: Prepared for Geriatrics by Judith Neugroschl, MD time napping also is common. Night-time sleep disturbances, especiallywhen associated with wandering and vide structured activities and socializa- can precipitate or exacerbate agitation.
tion, which allow for a safe outlet for pa- tients and respite for caregivers. Patients Affective and anxiety disturbances. Ma-
key to effective patient management.
of the Alzheimer’s Association, churches, Environment. Ensuring that a patient’s
mentia frequently have little interest in tients with orientation to time. Patients Autonomy and freedom. Restraints may
in rare instances. An alternative is to give ABCs. The mnemonic “ABC” is a re-
walking, wandering) can occur safely.
to the Antecedents to disturbing be-
havior, the nature of the Behavior, and
the Consequences of behavior. Once the
a caregiver diary—it is possible to in- Ensuring safety. At any stage of de-
be tried first so as to avoid introducing Activity planning. Daytime interventions
include exercise, socialization, and recre- decrease the potential for conflict in the minimize the risk of behavior episodes.
April 2002 Volume 57, Number 4 Geriatrics
CME Geriatrics
Table 3 Pharmacotherapy for behavior disturbances in dementia* Starting dose
Total dose/d

Common: EPS, akathesia, TD, acute dystonia Risperidone
Common: sedation, EPS (less common than withhaloperidol), hypotension, TD, hyperglycemia Olanzapine
Trazodone HCl


Serious: Agranulocytosis, aplastic anemia, hepatitis, thrombocytopenia, Stevens Johnson syndromeCommon: Sedation, unsteadiness Valproic acid
Serious: Hepatic failure, pancreatitis, bone marrow Common: Nausea, sedation, tremor, hair loss, ataxia Gabapentin
Serious: LeukopeniaCommon: Sedation, ataxia, tremor *Supporting literature for these recommendations can be found in references 9-11,14-17 NMS: Neuroleptic malignant syndrome is a rare, potentially life-threatening idiosyncratic reaction characterized by severe rigidity,hyperthermia, confusion, markedly elevated creatinine phosphokinase, and unstable vital signsEPS: Extrapyramidal symptoms; includes bradykinesia, tremors, and rigidityTD: Tardive dyskinesia Source: Prepared for Geriatrics by Judith Neugroschl, MD adverse events were seen.10 These results fects. Table 3 summarizes the dosing rec- scale trials that more effectively answer agement of specific agitation symptoms.
Antipsychotic medications. Several large
Antidepressants. Trazodone is a het-
if that fails, intermittently thereafter.
ential serotonin reuptake inhibition.
tion, findings showed no significant dif- a higher rate of adverse events (bradyki- Geriatrics April 2002 Volume 57, Number 4
Mittelman MS, Ferris SH, Shulman E,Steinberg G, Levin B. A family similar in efficacy, but the selective sero- disease. A randomized controlled trial.
Mood stabilizers. Carbamazepine (Tegre-
10. Teri L, Logsdon RG, Peskind E, et al.
tol, Epitol), valproic acid (Depakote, De- trial. Neurology 2000; 55(9):1271-8.
11. Devanand DP, Marder K, Michaels KS, et agitation. Most of the literature consists of open-label trial results, retrospective dose-comparison trial of haloperidol forpsychosis and disruptive behaviors in pressants, and mood stabilizers. G
placebo-controlled trial that enrolled 225 Download this article in PDF format.
dian dose), decreased aggression and pro- Log on to www.g
Log on to www
aggression and agitation in patientswith dementia: Efficacy and safety of Always on call.
efficacy, tolerability, and safety of dival- 13. Street JS, Clark WS, Gannon KS, et al.
behavioral symptoms in patients withAlzheimer disease in nursing care most frequent side effects with divalproex acid, serum levels, CBC and hepatic func- 14. Katz IR, Jeste DV, Mintzer JE, Clyde C, patients with Alzheimer’s disease. J Am 15. Sultzer DL, Gray KF, Gunay I, Berisford innervation in Alzheimer’s disease.
haloperidol for treatment of agitation in DF, et al. Fenfluramine challenge test as 17. Navarro V, Gasto C, Torres X, Marcos T, Pintor L. Citalopram versus nortriptyline if the patient fails two or more trials of Psychiatr Scand 2001; 103(6):435-40.
18. Tariot PN, Erb R, Podgorski CA, et al.
ing the side effects of the medications.
19. Porsteinsson AP, Tariot PN, Erb R, et al.
Geriatr Psychiatry 2001; 9(1):58-66.
bance, physicians should create a 8. Drevets WC, Rubin EH. Psychotic Turn to page 40 to take the exam
e the exam
type. Biol Psychiatry 1989; 25(1):39-48.
April 2002 Volume 57, Number 4 Geriatrics
Detach or photocopy this page, place an X in the boxes that correspond to your answers, fill in your name and address, and mail (see addressbelow). Answers must be received by October 1, 2002. A score of at least 80% must be earned to receive CME credit.
Make check for $15 payable to The Page and William Black Post-Graduate School and mail it with this exam to Rae Ann Houghton,Geriatrics, 7500 Old Oak Blvd., Cleveland, Ohio 44130. When submitting more than one exam, attach a separate check for $15 to eachexam. Documentation of earned credit and the correct answers will be mailed to you. Allow up to 12 weeks for notification.
Accreditation. This activity has been planned and implemented in accordance with the Essentials and Standards of the AccreditationCouncil for Continuing Medical Education (ACCME) through the sponsorship of Mount Sinai School of Medicine. Mount Sinai School ofMedicine is accredited by ACCME to provide continuing medical education for physicians. Mount Sinai School of Medicine designates thiscontinuing medical education activity for a maximum of 1 credit in category 1 toward the AMA Physician’s Recognition Award. Each physicianshould claim only those hours that he/she spent in the educational activity.
Faculty Disclosure. It is the policy of Mount Sinai School of Medicine to ensure fair balance, independence, objectivity, and scientific rigor inall its sponsored programs. All faculty participating in sponsored programs are expected to disclose to the audience any real or apparentconflict-of-interest related to the content of their presentation, and any discussions of unlabeled or investigational use of any commercialproduct or device not yet approved in the United States.
Neugroschl J. Agitation: How to manage behavior disturbances in the older patient with dementia. Geriatrics 2002; 57(April):33-37.
1. Pharmacologic intervention for agitation is indicated 5. Delirium, pain syndromes, infection, bladder distention, and fecal impaction can cause agitation, exacerbate it, Ⅺ a. has a corresponding Medicare reimbursement or lead to dementia-related agitation.
Ⅺ b. has been documented by a caregiver and family 6. For pharmacologic management of agitation, attempts to reduce and eventually stop medications should be Ⅺ d. prevents the patient from functioning or creates 2. Which of the following can aid the daytime management Ⅺ a. structured activities and socializationⅪ 7. In assessing a patient who displays agitation, it is im- b. maintaining bathing and toileting schedules Ⅺ c. enrolling a patient in an adult day care program Ⅺ a. the duration, frequency, and severity of symptoms Ⅺ b. the pattern of the disturbance (eg, time of day an Ⅺ c. the caregiver’s understanding of drug-drug inter- Ⅺ d. when a patient criticizes managed care 8. In the work-up of the patient who exhibits agitation, the 4. Sadness, tearfulness, suicidality, feelings of worthless- ness, and melancholia are distinguishing signs of:Ⅺ In addition to the exam questions, answer the following evaulation questions: (1=strongly agree, 6=strongly disagree)
1. The information presented in this article was useful.
2. The information presented was fair, objective, and balanced.
Your name: ____________________________________________________ Address (Street): _____________________________________________________________________________________ (City)______________________________________ Phone (include area code): __________________________ Specialty: GP____ FP____ IM____ DO____ Other (specify) _______________________________________________ Date:_________________ Signature: ___________________________________________________________________ Geriatrics April 2002 Volume 57, Number 4


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