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Managing Agitation in Dementia

Dementia is the decline in the normal functioning of cognitive abilities. It mostly appears after the age of 65. The most effective cognitive areas in dementia are memory, language and problem solving. Alzheimer’s is considered as the most common type of dementia. Dementia is the cause of agitation mostly in the elderly people. Agitation is referred to as discomfort, distress and behavioral changes related to dementia. The clinical question raised in this synthesis paper is “Are the non- pharmacological interventions more successful as compared to pharmacological interventions for the treatment of agitation in dementia found in elderly people?”

A person, who has a family member suffering from agitation, comes to think of himself as being in the worst of conditions, whereas about 5.2 million people in America are suffering from dementia and its consequences (Alzheimer’s Association, 2008). Delirium is a manifested dementia. The death rates due to delirium are 25-33% in hospitals (Nassisi, Korc, Hahn,et al, 2006). There are different views for the treatment of this acute, important and spreading disease. Two approaches are used for the treatment: pharmacologic and non- pharmacologic approach. The pharmacologic approach deals with treatment through medications, which in a sense is the cure through chemicals, whereas the non-pharmacologic approach is the treatment through different therapies and specific environment. The medicated cure is done by a doctor while the non-medicated cure is done by a careprovider.

Through our findings, it has been apparent that medication in normal dementia appears to increase the agitation and cause adverse effects on the elderly person. Through a research, it was found that dementia-curing drugs cause unhealthy effects on the patients, such as the problems in cognitive abilities, urinary tract infection etc. (Shneider, Dangerman&Insel, 2006). Moreover, there is always a huge risk associated with antipsychotic drugs that they increase confusion in the patient’s mind. These drugs decrease the cognitive abilities and daily functioning which affects the quality of life of the patient (AM J, 2011). There is less capability in elderly to respond properly to a medication. This clearly proposes that elders suffering from agitation cannot follow the true path of recovery through medicines (Nassisi, Korc, Hahn, et al, 2006).

To clearly understand the need of non-pharmacologic treatment for patients with agitation of dementia, there is a need to know the symptoms of agitation clearly. Dementia is featured as a decline in memory and often paired with the problem of normal body execution (Pelletier, Landerville, 2007).  Agitation is referred to as any inappropriate act by the mental patients. This may include wandering, shouting, hitting, hallucinations and depression seen in the patients of dementia. Agitation is directly related to discomfort. Discomfort is a negative thought emotion in response to the changing environment (Pelletier, Landerville, 2007). If a patient shouts or hits, he is basically trying to show his pain through actions which appear inappropriate to others. The agitation occurs in dementia patients mostly in specific and critical conditions (Kahn, Gwathyer, Frances et al, 1998). These patients are poor in handling changes around them. They are also very sensitive to their specific routine. The ideal environment for them is one being clear and easy to manage. Insomnia is also very common among dementia patients. Thus, their minds are inactive during the day and cannot control their actions properly. Physical syndromes are also related to dementia; these are anger, depression and anxiety. Anger is where a person loses his ability to control anger. Such a person exhibits unwanted insults, complains and screaming. Depression is a state in which a person loses interest in stuff that he once used to enjoy. Such a person seems aimless, and loses appetite and weight, while thoughts of discouragement run through his mind. Anxiety is affiliated to a person, who is way more nervous and fidget as compared to the normal levels. He is always having nausea and tachycardia for unknown causes. It is apparent through this research that most of these causes are affiliated with the mental and environmental conditions of the patient. As stated earlier, anti-psychotics are not a favorable solution of dementia; thus, for these aligned causes, non-pharmacologic treatment suits better.

To properly understand the importance of non-pharmacological interventions, it would be better to take a look at these interventions for the agitated patients with dementia. There are different kinds of therapies mentioned in the detailed research of Simon, Ian and Cliveand often practiced for its treatment as well (Douglas, James &Ballard, 2004). The most important is the reality orientation. The patients are told reality factors about their life and their environment to keep them in touch with the real “Them”. The other therapy is the validation therapy, which allows the therapist to make the patient flow in the past by repetitive actions in connection with the patient’s life. The third is the reminiscence therapy, which allows for the patients to relive their past experiences having positive effects on them, through gatherings. Family holidays and weddings are significant in this therapy. Other helpful therapies include the drawing therapy, which allows the patient to express his feelings through drawing and painting. The music therapy helps to decrease the violent behavior of the agitated patients. The aromatherapy is the most advantageous of all. It uses oils generated from lavender and Melissa balm. The oils are used for inhaling, massage and bathing of the patients. They are good for the sensory abilities and relaxation of the patients. Physical activities are also helpful for the agitated patients as these keep them busy and increase healthy movements.

There is a lot of evidence present in our research studies, which points out the importance and efficacy of non-pharmacologic treatment for agitation with dementia. Dewing proposes for a “person centered” treatment as the first line of approach for curing dementia, thus declining the medication treatment (Dewing, 2010). Another research and systematic review was done by Kong, Evans and Guevara in 2009 on the comparison of non-pharmacologic and pharmacologic interventions for cure of agitation in dementia. The research included 7 non-pharmacologic interventions (sensory, social contact, activities etc.) compared with medications and restraints. The results showed that out of all the therapies, the aromatherapy resulted in decreasing 35% of agitation, while many medications showed severe effects by increasing and worsening agitation. Another research shows that the rate of mortality in severe cases of agitation by dementia increases with the use of atypical antipsychotic treatments (Nassisi, Korc, Hahn et al, 2006). This clearly increases the demand of an alternative which is none other than non-pharmacologic approach. Through research, it has been found that the patient with mental illness should be referred to some mental doctor and treatment only in the case that his condition is very severe and there appears no other alternative (Dewing, 2010). It was proposed that in a case of agitation, the patient should be treated by simple to more effective stimuli before turning to medication with worse side effects (Mansfeild, Marx, Ali et al, 2010).

All this evidence led us to the support of our synthesis question that if the non-pharmacological interventions helped more in the cure of agitation with dementia as compared to pharmacological treatment. It appears that they are way more helpful as compared to medication because they bear healthy and permanent effects with nearly zero percent side effects. On the contrary, medication for psychotic diseases carries harmful effects for the patients, especially for elderly patients. The evidence is sufficient to hold in support of the synthesis paper question. As for the research work done, there is still some need for more research to be done on the long-term effects of non-pharmacological interventions on patients with agitation in dementia. This will help the public to be more certain about the well being of patients through these interventions. The progression of dementia to delirium would be avoided.

There is a need to practice change of treatment for agitation in dementia. This requires a whole change from the thinking of the patients, their care givers and their relatives to the doctors. From our research and evidence, the information gathered builds an effective way of treatment of agitation in dementia. As this problem is mostly faced by elders, my proposed practice change idea mostly refers to the nursing homes and their faculty. This practice change involves physical, social and mental activities for treatment.

The first step to be taken for practice change is the change of treatment. Thus, through researches and studies, a selection of necessary non-pharmacological interventions for agitation cure is to be taken and followed. The most necessary is the aromatherapy. This therapy should be frequently done by Melissa balm oil. It is referred to as one of the most effective treatments for agitation. Other therapies are the reality and validation therapies. Regarding the massaging activity, many researchers have been done which show the effectiveness of massaging in patients of agitation, especially foot massaging. A research showed that foot massaging creates a calming and satisfying sensation, leading to the production of oxygen, thus decreasing discomfort. As discomfort is directly related to agitation, the agitation decreases (Moyle, Jhonston&Dwyer, 2011).

Apart from these therapies and massages, a special environment for the patients is very necessary. A simple environment should be maintained. A very easy-to-do schedule of the patients should be proposed and then strictly followed. The reason for this is that the agitated patients are quite negative about changes. Noise and polluted music should be avoided. Simple meals should be given to the patients. There should be a schedule for some sort of physical activities of the patients. Sports are a very good option because these not only make the patients healthy but also are a refreshing exercise for their minds. Music is lovable for every perfect or diseased elderly patient. Singing and dancing can serve as means of expressing themselves on their happy times. Most of the agitated patients show problems in bathing. This problem has been researched upon and a solution has been proposed. The proposed solution is to overcome this problem by person centered showering and towel bath. It has been shown that such type of bathing results in a considerable decrease in discomfort during bathing for the already agitated patients (Sloane, Hoeffer, Mitchell et al, 2004).

One problem that arises is to decide that which sort of treatment should be given to which type of patient? This problem can be solved by proper experience and a firm grip over the methods and their effects. Through proper studies on elongated time spans, such a command can be achieved. Proper evaluation of the patients should be done by psychiatrists (Nassisi, Korc, Hahn et al, 2006). There should be ratings for the worsened condition of agitation in dementia among the patients. There should be proper discussions among experienced doctors and nursing residents, and then, a treatment plan should be devised for a specific patient. The plan can change with the changing condition of the patient. In case of severe dementia, where there seems no way out for survival, the patient can be put on medication. But in normal dementia, the non-pharmacological interventions should be considered the first and the only approach for cure.

All these are just the major discussions for the treatment of the agitated patients. But the efficacy of these treatments depends considerably upon the caregivers. As we are dealing with nursing homes here, the correspondents of nursing homes should allocate optimum number of workers for handling all these activities of the patients. The nurses should be trained properly for the activities proposed for the patients. These activities are of paramount importance as they have a soothing and calming effect on the patients and prevent them from indulging into the inappropriate and destructive activities of the agitated elders.  A research done on the prevention of agitated behavior in nursing homes resulted in the determination of optimum stimuli for treatment of agitation with dementia. Thus, there have been many other researches done which have led to a number of activities for the cure (Mansfeild, Marx & Ali, 2010). The nurses should also spend enough time with ill patients, so that, they might learn about their specific tastes and develop a language to understand their emotions. As agitation is nothing but their way to express their pains, the nurses should be close enough to them that they understand their pains and are able to ease them (Dewing, 2011). There should be head nurses related to agitation whose job should be to keep rounds in the building and put a check on the environment. They should prevent any noisy or receptive change from taking place in the surroundings of the agitated patients as it can result in a strong reaction by the patients. Special seminars should also be conducted to teach the patients’ relatives an effective way of interaction with their patients. These measures will help the patients to reflect the positive features of their past. Weekly meetings of every patient with the psychiatrist should be maintained properly.

This is a rough plan for a huge change of practice in the treatment of agitation in dementia. There can be many obstacles in achieving this effective change. One huge obstacle is the expenditure on the proper training of the nurses. This is a very sensitive matter, so, proper training will lead to positive results. Thus, a team should be fixed to guide the senior residents who will then convey this training to other nursing home workers. A proper guideline should be put down for the therapies and activities. The government should help in budgeting for this huge change.  This budget can be easily managed by incorporating the large budget for Alzheimer’s disease into this program.

Another huge obstacle is the need for quick results. It is human nature that one desires for quick improvement in one’s patient’s condition. Thus, many relatives of the patients resort to giving medications to the patient in order to get quick results. To prevent this, the pharmacists should be legally advised to give anti-psychotic medication only to people with proper prescription. And the relatives should be made aware by public voices and electronic media about the harmful effects of anti-psychotic medication. Another problem can be the inappropriate evaluation of the patient’s level of disease and the improper allocation of treatment plan. This obstacle can only be overcome by experienced workers. So, in case the progress of the patient is slow, his treatment plan should be revised, more efficiently. There are no cultural or ethical barriers in this change of practice.

This huge plan can be implemented in a relatively small scale period as compared to the large impact it will have on the patients in elderly homes. A greater time scale will be needed for properly training the nursing home workers. No compromise can be done in this respect. Thus, this practice change can be achieved in a period of about 3 to 4 years. An evaluation method should be formed to check the success of the change in treatment. The most logical evaluation plan for this practice is to form a group of experienced caregivers and a psychiatrist for an area. The progress of every patient of the nursing home should be recorded properly and regularly. This group should visit all the major nursing homes periodically and take notice of the patients, the new devised plans and the co-operation of the Nursing home residents in putting an excellent environment for the cure of the patients of agitation with dementia. This team will not only record their progress but also guide them into the right direction in case of being misguided. Different sort of data shall be collected, including the patient’s rate of functioning of cognitive abilities, patient’s progress in memory and the patient’s response to the changes in the environment. These and other sets of information will measure the patient’s gap with normal living.The statistical view of progress from all the areas should be collected and a final statement should be made. Changes should be illustrated and given practical shape if needed.

This synthesis paper gives us the appropriate information regarding the acute problem of management of agitation with dementia. The evidence points out that the most favorable treatment for agitation in dementia is the non-pharmacological one. A full practice change plan has been devised for the treatment of agitation by the non-pharmacological approach, leading to positive results for the betterment of the patients. This synthesis paper is a ray of hope for the depressed relatives and caregivers of the patients, that the agitated elders with dementia can also lead a positive life by properly following easy therapies and activities.

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