Clinical conundrum: Care home demanding sedation for a dementia patient

In the next in our series, GP and dementia lead Dr Peter Bagshaw considers how to handle this clinical conundrum in which a care home is demanding sedation for an elderly patient with dementia.

While duty doctor in your practice, you receive a call from a frazzled-sounding member of staff at the local elderly care home. She is concerned about an 88-year-old man with dementia who in recent weeks has been suffering increasingly frequent bouts of agitation during which he can become verbally aggressive. These episodes are particularly troublesome at night and are distressing the staff and other residents. She asks you to prescribe a sedative.

1. What might be the underlying reason for a deterioration of this sort and what non-medication approaches might help? 

Behavioural and Psychiatric Symptoms of Dementia (BPSD) are often a core part of the syndrome of dementia, and up to 90% of patients will experience them at some point.

Manifestations can include: agitation; aggression; wandering; hoarding; sexual disinhibition; shouting; repeated questioning; sleep disturbance; depression; anxiety; and psychosis.

(Note, however, that some working with people with dementia dislike the term BPSD, feeling it is stigmatising).

Despite the widespread nature of these symptoms, it is essential to look for an underlying cause rather simply assume the symptom is part of the patient’s dementia. The most important cause, particularly if the history is short, is an underlying infection leading to delirium. Even when the deterioration has occurred over several weeks, as in the current case, it is essential to exclude infection (especially a urinary tract infection) before looking at other options.

Other common underlying triggers include pain, constipation, depression, anxiety or insomnia. Pain may not be described by the patient, so looking for clues such as distress when moving, and considering a trial of analgesics, is worthwhile.

‘Sundowning’ is a term given to a worsening of symptoms in the evening or night. It can be particularly difficult to manage if it disturbs other residents. The phenomenon is not fully understood but simple measures such as gently increasing lighting and ensuring there are no disturbing shadows or reflections can be helpful.

Assuming no treatable cause has been found, a number of non-medication approaches have been shown to help, including:

• Physical presence and therapeutic touch therapy.
• Meaningful activities to allow for a sense of structure and social interaction.
• Psychological and psychosocial interventions for patients and their family.
• Environmental interventions such as the design and layout of the physical environment can make a huge difference (see below for examples).
• Compensating for sensory impairments with hearing aids and glasses.
• Complementary therapies (eg, massage, reflexology, aromatherapy).
• Access to pets, either real animals within the home, or robotic pets.

Behaving calmly in the face of distressed behaviour, and not challenging views we may know to be incorrect, are important whenever managing a person with dementia.

Although it is tempting to reach for a prescription in this scenario, the use of a ‘chemical cosh’ should be resisted wherever possible. Finding an underlying reason for BPSD can take time that few of us have, but can also be rewarding, and lead to dramatic improvements.

Examples that can make a big difference in my experience include removing mirrors from a patient who was convinced they saw their parent in the reflection, and changing the flooring when a shiny floor was mistaken for water. In one home I visited, patients were very upset by a locked door they felt was preventing them from returning ‘home’. Covering this with a picture of a local landmark reduced their distress significantly.

2. What are the risks of using sedative medication in this kind of situation? 

All sedative medication can be harmful, and can potentially worsen confusion and aggravate rather than improve this situation, as well as increasing the risk of falls. Antipsychotics, the traditional choice in BPSD, are particularly dangerous, increasing the risk of a stroke threefold, as well as the risk of impaired cognition and falls common to all sedatives in this population.

The 2006 NICE guidance on treating dementia (updated in 2018) included specific recommendations for antipsychotics in this population:

• People with dementia who develop non-cognitive symptoms or challenging behaviour should be offered a pharmacological intervention in the first instance only if they are severely distressed or there is an immediate risk of harm to the person or others.  
• People with Alzheimer’s disease, vascular dementia or mixed dementias with mild to moderate non-cognitive symptoms should not be prescribed antipsychotic drugs. Those with Dementia with Lewy Bodies (DLB) are particularly at risk of severe adverse reactions.   

3. If there seems no option but to try some kind of sedative, which best balances efficacy and safety?            

If any medical intervention is felt to be essential the mantra of ‘start low and go slow’ is useful, as this group is far greater risk of drug side-effects, as well as close monitoring and stopping if side-effects or no clear benefit. A therapeutic ladder of interventions suggests:

• Paracetamol, 500-1000mg up to QDS. Although paracetamol is often overlooked, it seems to have a calming effect in some patients even without overt pain, and is well worth a trial.
• Acetylcholinesterase inhibitors (eg, donepezil) or memantine may be beneficial, if not already prescribed. In a few patients on these drugs, stopping them can also paradoxically be helpful sometimes.
• The antidepressants trazodone, sertraline, or mirtazapine may be useful in obvious depressive symptoms (other antidepressants including citalopram are not recommended due to side-effects such as a prolonged QT interval).
• Lorazepam may be cautiously considered for short periods in severe acute distress. Its short half life make it the least worst benzodiazepine, though it still risks worsening cognition and falls.
• If an antipsychotic is felt to be the only alternative, risperidone is the only licensed antipsychotic for short-term treatment of BPSD. Other antipsychotics can be considered off licence, but this should really be the realm of secondary care.
• Finally, carbamazepine may be cautiously considered if other options are ineffective or contraindicated

In general, it is worth working through this ladder on a trial basis, moving to the next stage if ineffective, as we would with the pain ladder. If medication is felt to be essential, it is worth remembering that a phase of BPSD will often last for only six months or so, and a trial of titrating down medication is always worthwhile. Remember to go gently, and review the effects.

Dr Peter Bagshaw is a GP and NHS Somerset ICB mental health and dementia clinical lead