Assignment on Managing agitated Elderly with Dementia

Annotated Bibliography

Isabelle Chantale Pelletier and Philippe Landreville. (2007). Discomfort and agitation in older adults with dementia. BMC Geriatrics, 7:27.

This article focuses mainly on the relation of discomfort with noticeable agitation in older adults suffering from dementia. These adults are all above the age of 65 and have various levels of disability in performing daily activities. Agitation in the older adults was evaluated using Cohen Mansfield Agitation Inventory. Discomfort level was measured by the nine indicators of the discomfort level ensuing from dementia of the Alzheimer’s type. Registered Nurses were asked to collaborate in this study and provide the necessary observable data about the residents. The article concludes that relation of discomfort is particularly strong with adults with verbally aggressive behavior and non-aggressive physical behavior.

DENISE NASSISI, M.D. et al. (2006). The Evaluation and Management of the Acutely Agitated Elderly Patient. THE MOUNT SINAI JOURNAL OF MEDICINE Vol. 73 No. 7, 976-984.

The article talks about the need to realize what a fatal condition delirium brings about in elderly agitated patients if not treated fast and efficiently. Agitation is nothing but manifestation of delirium. Delirium in elderly people on their admission into hospitals must be addressed immediately as this is seen one of the major causes of their deaths. The proper pharmacological treatment is detailed over here along with the non-pharmacological treatment. Also the delirium status should be examined, evaluated and measured in the elderly as sometimes it takes a very subtle form.

Discomfort is evaluated and measured in relation with agitation in elderly people. This was a correlational study using a cross section of registered nurses. The RN’s were highly qualified with long experiences and were also demonstrated how to conduct trials for research purposes with the residents. The sample size estimate was near 50 which are allowed by the power analysis for Pearson coefficient. The effect size determined from the correlation between discomfort and agitation was 0.4 which is between medium and large. The level of cognitive impairment was measured using the Functional and assessment staging (FAST) used by Reisberg. SMAF was used to measure the level of disability in performing daily activities whereas agitation was evaluated using the French version of the CMAI.

The study has a high level of evidence based research as the evaluation and measurement process is a Meta- analysis of many RCT’s. It also correlates very strongly the discomfort factor with agitation especially in VAB and NAPB patients.

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Delirium is a major cause of death in agitated elderly people and it has to be defined and diagnosed properly. The Mini-Mental status examination is an easy and reliable test that can be administered at the bedside. The confusion Assessment Method has been used has an effective tool for measurement of delirium. Therapeutic intervention is recommended in most cases of elderly patients suffering from delirium. Patients should be provided with optimum level of sensory stimulation to reduce agitation. Pain has to be reduced by the administration of analgesics to patients but other medications should be avoided. The efficacy of some drugs in controlling delirium has been discussed in clinical detail.

The evidence based research here is not very strong because most of the administration of pharmacological interventions is not gone through extensive trial and testing. But the study shows that mortality rate in agitated elderly suffering from delirium increases with atypical (second generation) antipsychotic medications.

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The paper analyzes agitation as a symptom which can be dealt with more effectively by non-pharmacological interventions. It talks about the ways of understanding behavior of elderly people suffering from dementia as detailed by Cohen-Mansfield(2008). It lists the entire inventory of agitated behaviors as described by Rabinowitz et al(2005). It has looked at the care givers perspective and has explained their difficult situation when dealing with agitated elderly with dementia. It is also suggested that proper evaluation needs to be conducted before treatment can begin. The recommendation of the patient to mental health services should be minimal and only after extensive treatment suggests no other alternative.

The evidence here has been properly analyzed and presented with the authors own suggestions on treatment and care giving. The author has concluded that dementia and its symptoms worsen with chemical restraints.

The study was based on a systematic review and meta-analysis. The procedure of the analysis was based on the eight steps suggested by Egger and Smith. A thorough literature review was conducted for dealing with dementia in the elderly by using non-pharmacological methods. Cochrane criteria were used in assessing allocation criteria and withdrawals or dropout in the methodology. The main outcome of the study is the specific effective non-pharmacological interventions used. There were two reviewers and in case of a confrontation, the third reviewer was consulted. The main outcome variables were different intervention methods and though they had different time intervals and different scales, standardized mean difference with 95% confidence levels were used to estimate pooled effect size.

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The evidence and results are very strong in suggesting improvement in dementia of the elderly agitated patient by the use of non-pharmacological intervention. The study is limited by the small sample size for each intervention.

The study has researched well into the management of care for agitated elderly with dementia. They have proposed non-pharmacological methods which are more effective than other methods to the care givers who face extreme challenge in dealing with elderly patients with dementia. Only in very adverse cases have chemical restraints been suggested according to the results of the population. The five senses have been categorized separately so that treatment can be facilitated accordingly.

Here the study is based on a lot of research done previously especially by Dewing(2010). The explanation of the methods of non-pharmacological interventions to reduce dementia is extensive.

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