Agitation is a neuropsychiatric syndrome that is commonly seen in those with major neurocognitive disorders. Those demonstrating agitation can show increase in motor activity, restlessness, emotional distress, and physical or verbal aggression. Agitation is the third most common neuropsychiatric symptom in dementia after apathy and depression. Up to 80% of people with dementia experience some degree of agitation at some point during the course of the illness. The pharmacologic management of agitation in those with major neurocognitive disorders is complex and many studies have shed light on the topic.

Sexually inappropriate behavior can be a manifistation of disinhibited behavior seen in older adults with major neurocognitive disorders. Sexual expression in older adults with major neurocognitive disorders is normal and should not be universally discouraged when in an appropriate setting and when the rights of others are not violated. The evaluation of sexually inappropriate behavior should include a detailed history that includes what the behavior is, who is involved, what is the context of the behavior, who is being impacted, and if the behavior is out of proportion with other disinhibited behaviors. Look for and potentially remove medications that could be contributing to sexually inappropriate behavior including dopamine agonists, anticholinergic agents, and benzodiazepines.

Primary health care providers and mental health professionals are likely to be engaged with family or care staff with questions regarding end-of-life care issues in those in the terminal stages of major neurocognitive disorders. Those who provide care in the long-term care setting should be familiar with issues regarding end-of-life care in MNCD. Palliative care is an approach to medical care that focuses on providing relief from pain, other symptoms, and the physical, emotional, and psychosocial stress that individuals with serious illnesses may experience. The primary goal of palliative care is to improve the quality of life for patients and their families, particularly when dealing with complex, chronic, or terminal medical conditions. Hospice care is appropriate for patients that are entering the terminal stage of illness and is provided through a licensed hospice agency. The hospice care model focuses on improving comfort and quality of life. It is a holistic approach that encompasses physical, emotional, social, and spiritual support and can be provided in almost any care setting.

Biopsychosocial-spiritual distress, also known as agitation, can be experienced by anyone with unmet biological needs, safety needs, need for love and belonging, and need for self-actualization. Signs of potential biopsychosocial-spiritual distress can include: restlessness, aggression, agitation, sundowning, wandering, exit seeking, social withdrawal, repetitive behaviors, and increased anxiety. Common unmet biopsychosocial needs in long-term care can include loneliness, boredom, pain, hunger, toileting issues, difficulty communicating needs, medical interventions, changes in routine, interpersonal conflicts, staff issues, and issues with other residents. Potential signs of psychosis in those with major neurocognitive disorders can include screaming out, picking at the skin, extreme agitation with personal care, talking to oneself, signs of compulsive behaviors, and the presence of paranoia. The presence of psychosis in major neurocognitive disorder may warrant the use of antispsychotic angents.

The implications of unrecognized pain in those with MNCD are far-reaching.  Untreated pain can lead to the destabilization of psychiatric conditions such as anxiety, depression, and agitation.  Those with cognitive impairments are more likely to have longer waits for the evaluation of pain and receive weaker analgesia.As needed pain medications given to those with MNCD in the LTC setting may depend too heavily on the judgment of those inadequately trained to assess pain.  Regularly scheduled pain medications may be a more appropriate option. Always keep the possibility of medication error in the differential diagnosis for apparent changes in mental status. Inadequate pain control negatively impacts mental health in older adults.  Those with MNCD with inadequately controlled pain may present with atypical symptoms when compared to those without MNCD. Consider both pharmacologic and nonpharmacologic interventions when formulating a treatment plan for chronic pain in older adults. Opiates may have the best benefit/risk ratio for the treatment of chronic pain in some older adults.

Alzheimer’s disease is the most common form of major neurocognitive disorder, causing gradual declines in many areas of cognition. Alzheimer’s disease accounts for 60-70% of cases of dementia worldwide. Donepezil is the prototypical cholinesterase inhibitor and was approved for use in 1996. It is FDA approved for the treatment of mild, moderate, or severe Alzheimer’s disease and is considered a symptomatic treatment for Alzheimer’s disease and some other dementias as it does little to alter the course of the disease. The advantages to maintaining patients on cholinesterase inhibitors include continued slowing of the decline in cognition, delaying need for a higher level of care, and potentially delaying the need for medications to address neuropsychiatric symptoms.