WHO is agitated?

The word “agitated” seems to be overly used in a long term care setting. It is often referred to a set of behavioural symptoms ranging from wandering to yelling, and in some extreme cases, aggressively hitting or hurting self or others.  These symptoms are thought to be a result of progressive dementia, more broadly defined as behaviour psychological symptoms of dementia (BPSD).  The first line approach is to redirect or distract the resident, or to attempt other non drug measures. But when these interventions are deemed inadequate or when safety concerns are at stake, prescribing anti-psychotics may become necessary.

However, there is a fine line between necessity and convenience.  

Recently, the media  has -in my opinion – unfairly portrayed the use of anti-psychotics in long term care facilities leading to public outcry. In reality, these anti-psychotics are needed in selected situations.  I admit, though that we can do a better job to taper or discontinue anti-psychotics more promptly when they are no longer needed.

The problem is once an anti-psychotic is started to manage a behavioural symptom, there is often strong resistance to reduce or stop the anti-psychotic when the resident has become stable again. The personal support worker may fear the rebound behaviour will put his or her safety at risk when feeding or bathing the resident. The nurse may be concerned with the return of paranoia or restlessness that will make every step of providing care challenging. The physician may want to leave things as is because he doesn’t see want to be paged in the middle of a night for an uncontrollable behaviour.

So what’s the rush to stop these anti-psychotics?

There is strong evidence that these anti-psychotics have safety concerns too. When used in the setting of dementia, it is found that those residents with dementia who take anti-psychotics for behaviour are at increased risk of stroke and death.  So their use must come with an honest assessment of their risks and benefits with each situation. No one outside the circle of care has a good enough understanding to be judgmental about it.

But when the resident is stable, we should try to taper the anti-psychotics. It is not always successful but we should always try. Failing to try is negligence.

I work closely with different long term care facilities to help reduce anti-psychotic use. I understand the challenge. I understand the resistance. Nurses and personal support workers have to deal with these residents face to face, has to endure abuse from the residents and they are often stretched to the limits with shortage of staff and resources.

When I see  the nurse pestering the doc to restart the risperidone at the first sign of any perceived agitation, instead of looking for more consistent patterns, rule out other potential reasons such as an infection and pain, it feels the push of the anti-psychotic is for the nurse’s sake, rather than genuinely caring for the resident’s safety.

Sometimes I wonder, who is really agitated here – the resident or us?

What if we turn the page and offer each of us a dose of Ativan instead? How will this manage the agitation better?  I gather such a practice will be seriously frown upon. We just need better stress management, better communications and better work life balance. Agitation is not only a concern for the residents with dementia. It is also a problem among the health care team in long term care facilities. It is a system wide issue and needs a system wide solution.



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My name is Cynthia Leung and I am a practicing pharmacist in Kingston Ontario, Canada. This blog is for me to share my ideas, opinions and perspectives on how medications are used in our health care system. Note that these posts are my own opinions and do not represent the opinions of my current or former employers and / or organizations that I may belong to. Any possible case scenarios described in my posts would be modified to maintain patient confidentiality. This blog is not a platform for professional advise for patients or health care providers and the content is not meant to support any clinical decisions or replace professional opinions. Also the images are either taken or created by the author, or adapted with permissions. I hope you will enjoy reading my posts!

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