Agitation: Ativan Is Not the Answer: Behavioral Intervention Is Always Best

We overmedicate our elders with dementia and agitation. When they are bored, and get restless or come asking questions for the 30th time, we treat them for “anxiety.” When they get extremely angry at us, or won’t sleep at night, or are slow to dress and swat back when they are hurried, they get medicated. This is not OK.

Let’s look at the alternatives. Nancy Shier-Anzelmo has been a Gerontologist teaching at Sacramento State University and developing programs for improving quality of life for over 20 years.

In her work, Shier-Anzelmo sees again and again that pills are used instead of trying to engage and interest the patient. If an elder is rummaging around, restless, and asking endless questions, she sees that that person is not engaged.

In the elder-care world, we talk a lot about “person-centered care.” But what is “person-centered” about prescribing pills when we could instead try to make the elder more engaged in his or her life?

Truly person-centered care would try to assess why a person is restless? What would they enjoy doing at this point? Would they like to be baking cookies, or would they prefer to be taking a virtual tour of the Metropolitan Museum of Art? Would they like to play Wii Bowling? Would they like to go out golfing, or sing with a group?

Like most of us, elders are less likely to get into trouble if they are engaged and busy. They are more likely to sleep well at night if they are active during the day. It may work for some communities to have elders with dementia up at night. But many facilities don’t have the same coverage at night, when a wandering elder may disrupt others, or get hurt.

I never advocate use of sleeping pills. One of the concepts I find most difficult to communicate to caregivers is really quite simple: If an elder is to sleep at night, he must be active during the day. He may need a one-hour nap, but if they sleep 2–4 hours in the afternoon, well, there goes good sleep for the night. More sleeping pills will not make an elder sleep more at night. Often, increased use of sleeping pills just makes the patient they often just sleep harder during the day.

I will address reorienting the sleep cycle in another post.

Here are a few tips though: Avoid Tylenol PM—a pain reliever is OK at bedtime. Benadryl, or any anticholinergic medication is not. (See the Medications page) Also avoid caffeine. You might need it, but elders will be much better off without it. Patients who cut out caffeine have fewer sleep problems, less bladder irritation, and less need to urinate at night.

We need to make sure that we address pain. Nothing makes me more sad than seeing agitated elder get an Ativan, when what they really need is a painkiller like Tylenol.

Arthritis can be painful. I am a fan of Tylenol 500 mg three times a day. (As with all medical issues in this blog—do not do anything without the direction of your doctor—a rare person should not take Tylenol, those with liver failure, or who are not eating and drinking well.) An elder with dementia did not get magically cured from his arthritis that he has had for the last 20 years. Now, he just cannot name his discomfort and ask for pain medication.

Sometimes the pain is so bad, that Tylenol does not treat it. I have seen elders with dementia who were very angry until their pain was better controlled, with a strong medication such as Vicodin or a very small amount of long-acting pain medications such as Methadone. (Again, don’t do this without consulting a doctor.)

We must also learn to take our time in helping an elder with dementia with activities of daily living. They process more slowly. Get down on their level, be friendly and gentle and give a choice of two options “Would you like the red pants or the blue pants?” Then wait. Don’t hurry or criticize clumsiness or repetition. Remember, an elder with dementia will reflect what they see and feel. If you exhibit anxiety or anger, the elder will reflect that back.

Teepa Snow, an occupational therapist, has many suggestions for how to help an elder with feeding or brushing teeth—activities that often result in anxiety. For instance, if you’re working with a right handed elder, shake with the right hand, then hook thumbs and bring your hand around with theirs; so you will hold the fork or the toothbrush, but you help them sense when something is coming to their mouth. If you use this technique, they are ready for something to happen. It results in much less surprise, fear and agitation.

In short, most agitation in dementia should be addressed with US changing our behaviors. Not pills. Often, the pills cause more problems than they solve.

Elizabeth Landsverk MD Geriatrician, House calls doctor for Marin, Burlingame, San Francisco, San Jose, Walnut Creek On call 24/7, working to avoid trips to the ER Working to reduce medications, and improve enjoyment of every day