Reduction and prevention of agitation in persons with neurocognitive disorders: an international psychogeriatric association consensus algorithm

OBJECTIVES

To develop an agitation reduction and prevention algorithm is intended to guide implementation of the definition of agitation developed by the International Psychogeriatric Association (IPA).

DESIGN

Review of literature on treatment guidelines and recommended algorithms; algorithm development through reiterative integration of research information and expert opinion.

SETTING

IPA Agitation Workgroup.

PARTICIPANTS

IPA panel of international experts on agitation.

INTERVENTION

Integration of available information into a comprehensive algorithm.

MEASUREMENTS

None.

RESULTS

The IPA Agitation Work Group recommends the Investigate, Plan, and Act (IPA) approach to agitation reduction and prevention. A thorough investigation of the behavior is followed by planning and acting with an emphasis on shared decision-making; the success of the plan is evaluated and adjusted as needed. The process is repeated until agitation is reduced to an acceptable level and prevention of recurrence is optimized. Psychosocial interventions are part of every plan and are continued throughout the process. Pharmacologic interventions are organized into panels of choices for nocturnal/circadian agitation; mild-moderate agitation or agitation with prominent mood features; moderate-severe agitation; and severe agitation with threatened harm to the patient or others. Therapeutic alternatives are presented for each panel. The occurrence of agitation in a variety of venues-home, nursing home, emergency department, hospice-and adjustments to the therapeutic approach are presented.

CONCLUSIONS

The IPA definition of agitation is operationalized into an agitation management algorithm that emphasizes the integration of psychosocial and pharmacologic interventions, reiterative assessment of response to treatment, adjustment of therapeutic approaches to reflect the clinical situation, and shared decision-making.

Agitation in Cognitive Disorders: Use of the National Alzheimer's Coordinating Center Uniform Data Set (NACC-UDS) to Evaluate International Psychogeriatric Association Definition

OBJECTIVE

Consensus-based definition of agitation by the International Psychogeriatric Association (IPA) has not been evaluated in community-based samples who are not preselected for behavioral disturbances. Here, we use a well-characterized cohort of community-dwelling older adults with cognitive impairment to assess the IPA criteria associated with agitation to evaluate the construction of this diagnostic entity.

METHODS

We used the National Alzheimer Coordinating Center Unified Data Set (NACC-UDS) to construct the IPA consensus-based provisional definition of agitation in cognitive impairment (N = 19,424). We used clinician diagnosis of agitation as a gold standard in those with mild cognitive impairment and dementia and used the Neuropsychiatric Inventory-Questionnaire to define agitation symptoms and standardized assessments of function (including the Functional Assessment Scale and Clinical Dementia Rating Scale Sum of Boxes) to assess "excess disability." We also examined patterns of psychiatric comorbidities to determine if they were consistent with IPA criteria.

RESULTS

There was agreement between the selected NPI measure of agitation and clinician judgment (sensitivity = 0.79, specificity = 0.69, Cohen's Kappa = 0.304). More than 84% of those with clinician judgment of agitation and 74% of those meeting the scale-based definition of agitation demonstrated excess social/functional disability. Comorbid psychiatric symptoms were present in 38% of the sample without agitation and higher in those with agitation by either definition.

CONCLUSION

Agitation ranges between 15% and 48% in those with cognitive impairment. The pattern of level of excess disability and the presence of comorbid psychiatric symptoms is consistent with the profile of published definitions.