UBC Objectives: Care of the Elderly & Priority Topic: Behavioural Problems

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Justify the indications, risks, alternatives, and contraindications for physical and chemical restraints

Key Feature 5: In elderly patients known to have dementia, do not attribute behavioural problems to dementia without assessing for other possible factors (ex: medication side effects or interactions, treatable medical conditions such as sepsis or depression).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

This week I will be starting my first week of being on call for a nursing home, where many of the residents have a diagnosis of dementia. One of the many challenges for caregivers of patients with dementia arise from the behavioural (i.e., neuropsychiatric) disturbances that can frequently accompany this disease process. I expect to be called regarding the management of these issues. The first step in addressing behavioural concerns in a patient with dementia is to consider a differential diagnosis. Sure, the behavioural concerns may just be a manifestation of this disease process as it affects behavioural regulatory centres in the brain, but they may also be an adaptive physiological response to some sort of noxious trigger. UpToDate provides a comprehensive table that lists common reasons for behavioural disturbance in patients with dementia that I will no doubt be referring to:

Sometimes it can take some time to figure out what the reason for a behavioural disturbance is. Other times, it's idiopathic. Regardless, in the moment the patient may be at risk of harming themselves or others, or caregivers are just having a hard time coping. In these cases, the best strategy is to apply behavioural techniques, such as ones that calm or distract, but these don't always work well enough. If a good effort at such techniques is made, or for whatever reason it's simply not feasible, then chemical or physical restraints may, unfortunately, be a last resort. Methotrimeprazine is a common agent used for agitation in the elderly in British Columbia, and haloperidol is also commonly used for acute agitation. Atypical antipsychotics are more commonly used on a chronic basis, but we know there is an association between antipsychotic medication use in dementia and greater mortality. While I hesitate to prescribe these unless absolutely necessary, sometimes it just is, in the interest of preventing the greatest harm. Physical restraints may be necessary while awaiting the calming effects of medications to kick in, but are even less desirable usually and they can stir up even more distress for the individual being physically restrained.