To the Editor: Agitation is a multifactorial problem that is frequently found in people with dementia. Consequences of this result in institutionalization in nursing homes, hospitals, or other structured living arrangements, which are very costly. For instance, the annual cost of nursing home care in the United States is over $50 billion; by 2030, it is projected to be over $700 billion (1).
Agitation in individuals with dementia occurs for different reasons. Medical causes most commonly include pneumonia, urinary tract infections, or other infectious diseases. Psychiatric causes include delirium, anxiety, depression, and psychosis. Pain is infrequently appreciated as an independent source of agitation in people with dementia. Unfortunately, unnecessary medical evaluations and even treatments may occur when pain is not appreciated as the source of the agitation; this may further aggravate the problem.
When pain is the source of agitation, treatment needs may be quite different. If they are not addressed, further suffering occurs, which further escalates the agitation. The following case illustrates this phenomenon, highlighting the need for early recognition and intervention.
Ms. A, an 86-year-old resident of a nursing home with a 4-year history of dementia of the Alzheimer’s type, was admitted to our hospital for further evaluation and treatment of progressive agitation. She had no psychiatric history before the diagnosis of Alzheimer’s disease. For the first 3 years after her diagnosis, she remained independent. In the fourth year, she had to be placed in a nursing home because of her inability to care for herself and the development of anxiety, dysphoria, and perceptual distortions, which resulted in her being placed on a regimen of paroxetine and haloperidol.
Ms. A had a long history of osteoarthritis, osteoporosis, and scoliosis, which affected her walking. Within 6 months of being in a nursing home, she fell and sustained a left intertrochanteric fracture, which required surgery. After surgery, she was only briefly treated with oxycodone. Shortly thereafter, she began screaming and became increasingly agitated, which escalated to aggressive behavior. At this time, she was transferred to our hospital for presumed worsening of her agitated depressive symptoms.
On admission, Ms. A was alert but oriented to person only. Although she was unable to give a detailed medical history, she consistently acknowledged significant discomfort, especially in her back and left leg. Her medications at admission were paroxetine and haloperidol, the doses of which had been recently increased in an attempt to control her agitation.
A medical assessment revealed no acute medical causes for her distress (including infection or cardiovascular or pulmonary changes). Untreated back and left leg pain was felt to be the most likely cause of her agitation; hence, she was treated with scheduled analgesics, including acetaminophen and ibuprofen. Within 2 days, her agitation markedly decreased, and her behavior was more appropriate. She was able to return to the nursing home; continued improvement was noted at her 1-week follow-up evaluation.
In nursing home residents, agitation is very common. Determining whether or not pain is the primary source of agitation is complicated by a cognitively impaired person’s difficulty in communicating his or her symptoms (2). The presence of dementia should not be an excuse for not doing a proper evaluation to identify and treat pain in elderly patients.