Optimizing Outcomes in AAD in Community PCP and LTC Clinics

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Dr. Porteinsson: 
This is CME on ReachMD and I'm Dr. Anton Porteinsson. Joining me today is Dr. Brendan Montano. Let's start by talking about how common agitation in Alzheimer's disease is and what are the early clinical signs.

There's often a misconception that agitation is only seen in moderate or late-stage Alzheimer's disease. It can be seen at any stage of the disease, even as early as the mild cognitive impairment stage, but it often starts in a subtle way. It may show itself as increasing irritability, short temperedness, being ornery, reject offers of assistance. And then, it can kind of escalate further to more verbal aggression, name calling, threats, slamming doors, hitting objects and even physical aggression. And in such situations, we obviously have hit a crisis. So, this type of behavior becomes more common as the disease wears on, but like I said, it can be seen early, so you need to kind of keep an open mind at any stage of the disease. And at any one time, a quarter to even half of patients with Alzheimer's disease or related dementias may exhibit various degrees of agitation. Often mild, but it can be moderate or even severe.

So, we need to be aware of this and we need to kind of understand that these conditions are near ubiquitous and at some time of the disease, almost everyone with dementia has some degree of this. And it causes a major challenge in terms of providing care, and particularly for the care partners. So, I want to kind of highlight the importance for providers to keep their eyes open and to understand that these symptoms can start subtly and then escalate. And sometimes escalate quickly.

So Dr. Montano, do you have anything to add from your experience? 

Dr. Montano:
Anton, I agree 100% with what you just said. Often in the beginning, a caregiver can minimize and marginalized the symptoms that their loved one has with dementia and agitation. But as time goes on, they wear out. As time goes on, they change their schedules. They frequently will have to leave work or almost leave work, and they will have to devote more and more time and have disrupted time when they are at home. Perhaps their diurnal sleep cycle is completely changed, which is more stress.

And when things erupt, really get bad, there can be physical aggression, which unfortunately is embarrassing for the caregiver and often is not even brought up at the interview. You almost have to ask when they come in. I have made it a if you will, a very important part of my interview. The last time that I recall it happening, a woman who usually always took care of her husband, who was partially blind and needed guidance and assistance into the office, didn't show up with him, the son showed up instead. And upon discussing it, it was because she had been hit by and assaulted by her husband. Obviously, something that never happened in 30-40 years of their marriage but was happening now. 

Dr. Porteinsson:
And Brendan, that's a very helpful clinical vignette and thank you for sharing it. I think that it just highlights the level of distress that can emerge in situations where agitation is a true clinical emergency.

Well, this has been a brief but great discussion. Our time is up. Thanks for listening. 

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