“Nursing homes ask province to help reduce violence among elderly”
Sensational headlines like these linking Alzheimer’s patients with violence have been appearing recently right across Canada. Threats of a growing problem are raised: approximately three quarters of a million Canadians are living with Alzheimer’s or a related dementia, and this number is expected to almost double by 2031.
It’s true that agitation or aggression is one of the most burdensome of a number of neuropsychiatric symptoms associated with Alzheimer’s dementia, one of the main causes of hospitalizations, and one of the main reasons for a transition from home to a long-term care home.
Currently, medications for agitation and aggression are modest in their effects but needed in severe illness. They are associated with serious side effects, including increased mortality. Judicious use of these medications is urgently needed.
Current clinical practice is often marked by high variability in their use or their inappropriate use. For example, it is not uncommon to see individuals being treated with more than one medication at a time without evidence of their combined benefits and subjecting them to excessive side effects and unnecessary costs. What can be done?
At CAMH, we have developed a systematic approach to assess and treat agitation and aggression in Alzheimer’s dementia. The approach is a multidisciplinary Integrated Care Pathway, where patients are treated in a standardized way by an interprofessional care team. Three main characteristics define our pathway:
1. Systematic assessment
2. Measurement-based interventions
3. Algorithmic approach to treatment
All individuals presenting with agitation of aggression undergo the same set of assessments, systematically. Such a systematic approach ensures that all factors, especially the reversible ones that could be contributing to the agitation or aggression are identified and addressed appropriately. Such factors include an infection, a loud environment, or pain. The assessment also ensures that side effects from medications are captured appropriately.
Following the systematic assessment, a quantitative measure with cut-off points is used to indicate whether an intervention is required. Interventions include a wash-out phase of all unnecessary and ineffective medications, personalized therapeutic activities such as music therapy and cooking classes, and medications. This process is also used to indicate when during the episode of care to adjust the intervention (e.g. increase the dose) or not adjust. This measurement-based decision process based on cut-off points eliminates the subjectivity of the clinician, ensures that variability in treatments is minimized, and outcomes are optimized.
Our pathway adheres to an algorithmic approach, particularly with regard to prescribing medications for agitation and aggression. Every person with agitation or aggression due to Alzheimer’s dementia is treated following a sequence of pharmacological steps that has been decided on in advance. The order within the sequence is based on evidence from the literature and the consensus of experts in the field. Not only the sequence of medications is decided on, but also the titration schedule is pre-determined. This pre-determined schedule of dose adjustment ensures that medications are not used below a therapeutic dose or above what is recommended. It also ensures timely switching to another medication if one is not effective.
This algorithmic approach can be perceived in opposition to personalized medicine, since every person is subjected to the same sequence. However, we argue that this approach actually optimizes personalization. The granularity of the algorithm, combined with the systematic assessments and measurement based adjustments, ensure that personalization is precise and guided.
We would argue that in evidence-informed care, personalization can only occur if it starts from a common standard. Otherwise, it is likely to be arbitrary and uninformed.
Preliminary findings from a new CAMH approach show that we can eliminate inappropriate use of medications for agitation and aggression, with good and successful clinical outcomes. The effect of our interventions on agitation and aggression overall is compelling.
Our society will continue to struggle with Alzheimer’s dementia in the foreseeable future. Optimizing the treatments that we have to minimize the personal and economic burden of this illness on the individuals, and their families and caregivers, will be critical for our society to cope with this illness.
Resources:
• Read more about the Integrated Care Pathway for Dementia Agitation and Aggression
• Read more about the development of an Integrated Care Pathway for the CAMH Memory Clinic
• Alzheimer’s Disease Infographic