Online Coverage from the 150th Annual Meeting
of the American Psychiatric Association
May 18 - 21, 1997
© 1997 Medscape, Inc.

How to Manage Aggression in the Elderly

Speaker: Pierre Tariot, MD
Reporter: Deborah Carver, MD

Introduction

The great majority of patients with dementia experience some psychopathologic symptoms that may lead to agitated and/or violent behavior. Aggressive behavior is distressing to all involved, but particularly so with elderly patients and frequently results in nursing home placements. Dr. Pierre Tariot, Associate Professor in the Departments of Psychiatry, Medicine, and Neurology at the University of Rochester School of Medicine, and Director of Psychiatry at the Monroe County Community Hospital in Rochester, New York, spends much of his time working with patients and families on the recognition and management of behavioral problems. In a presentation at the 150th Annual Meeting of the American Psychiatric Association he set forth a general approach for clinicians to follow in the assessment and treatment of aggressive behavior in the elderly.

Dr. Tariot defines aggression as "hostile actions directed toward self, others, or objects. These actions can be verbal, vocal, physical, or sexual." Examples include cursing, throwing objects, hitting, picking or scratching, and head banging. Aggression in the elderly is generally associated with a host of neuropsychiatric disorders such as delirium, dementia, seizures, and other neurodegenerative disorders. The aggressive behavior rarely meets syndromal criteria as defined by the DSM-IV.

Systematic Approach

Dr. Tariot advocates following a systematic approach to assessment and treatment of aggressive patients. First, characterize the target symptoms to be treated, either with or without the use of standardized assessment instruments. Determine whether the behavior is impulsive or planned (defined as anything greater than 24 hours). Next, assuming the situation is not emergent, thoroughly evaluate the patient to identify any diagnosable psychiatric, neuropsychiatric, or medical illnesses. It is critical, he emphasizes, to treat whatever can be treated before proceeding to address the aggression. Treatment of underlying disorders may alleviate many or all of the aggressive symptoms.

After diagnosing and treating underlying conditions, Dr. Tariot focuses specifically on the aggression. To do this he develops what he terms a "Psychobehavioral Metaphor," searching for a pattern in the patient's behavior which is analogous to that typically seen in a "drug responsive" psychiatric syndrome. Patients who display aggressive behavior may present predominantly as:

Using this psychobehavioral metaphor, patients are treated empirically with a medication that is effective in treating the parallel psychiatric diagnosis. With all medication classes, he advises, "start low, go slow" and hold at the lowest nontoxic dose with shown efficacy.

Drug Therapy

A thorough review of the literature shows 310 published reports since 1986 examining the use of multiple medication classes for the treatment of aggression. Dr. Tariot cautions that, overall, the data are limited, the methodologies vary, and there are at times differing agendas driving the research.

There have been a few controlled, double-blind studies documenting efficacy for aggression for several medication classes, however, with many more currently underway. Drug classes with demonstrated efficacy include anticonvulsants, antipsychotics, and antidepressants.

Anticonvulsants. While the goal is always to target specific symptoms, in general Dr. Tariot favors the use of anticonvulsants over other medications such as antipsychotics or antidepressants.

There are as yet no controlled studies published on the use of valproic acid or divalproex sodium for the treatment of aggression, but there are several open trials that are very promising. While thrombocytopenia can be a concern, in Dr. Tariot's experience the side effects and drug-drug interactions are fewer and more predictable for valproic acid than for carbamazepine.

Antipsychotics. The traditional antipsychotics have been widely studied and shown to be helpful in the management of aggression associated with psychosis of any etiology. In one controlled study (published by Schneider et al, 1990) patients treated with typical antipsychotics showed an improvement rate in agitated behavior 18% greater than those given placebo. Other studies show that modest effects have been achieved at low doses regardless of class.

Dosages should be minimized, Dr. Tariot advises, as side effects are significant with these medications. The side effect profiles of the newer atypical antipsychotics are appealing, but as yet no controlled studies have been completed. These studies are in process however, and should be published within the next few years. Many clinicians have been using these newer drugs empirically and report some positive response at low doses.

Benzodiazepines. Benzodiazepines are frequently used by primary care practitioners for the treatment of agitation and aggression because of their highly sedating properties. Dr. Tariot cautions their use however, unless there is a component of anxiety or sleep disturbance to the behaviors.

Benzodiazepines can paradoxically increase agitation, disinhibition, and the risk of falling in the elderly. Further, long-term use can be complicated by habituation and withdrawal. When the patient's symptoms support the use of these medications, the shorter acting agents, such as lorazepam or oxazepam.

Selective Serotonin Reuptake Inhibitors (SSRIs). Many clinicians are empirically treating aggressive patients with SSRIs. Only one controlled study evaluating antidepressants in aggression has been published. This study, which investigated the efficacy of trazodone, showed modest improvement in about half of the patients treated. Several other open trials show similar results.

Beta adrenergic antagonists. Beta blockers have not been studied in dementia but have been used with success in the management of severe and episodic violence associated with organic brain disease. As with the antipsychotics and benzodiazepines, side effects can significantly limit their use.

Other agents. The cholinergic agents are still too new to draw any firm conclusions, but they appear to have behavioral effects that warrant further investigations. Buspirone may be effective, but primarily at doses above 30mg. Lithium should probably be avoided given the potential adverse effects in the elderly. There are no data available yet on the use of hormone therapy for the treatment of aggression.

Conclusion

There are many currently available agents for the empiric treatment of aggressive behavior in the elderly, but large sample sizes and controlled studies are lacking. Over the next few years, more information will become available on all of these agents. It remains to be seen how emerging data may impact the approach to the treatment of these patients.

Current understanding supports the formulation of a psychobehavioral metaphor and treatment with anticonvulsants such as valproic acid, unless specific symptoms direct treatment with another class of drugs.

Suggested Readings:

  1. Tariot PN. Behavioral manifestations of dementia: A research agenda. International Psychogeriatrics. 8 Supp 1: 31-8, 1996
  2. Tariot PN. Treatment strategies for agitation and psychosis in dementia. Journal of Clinical Psychiatry. 57 Supp 14:21-9, 1996
  3. Tariot PN. Anticonvulsant and other non-neurologic treatment of agitation in dementia. Journal of Geriatric Psychiatric & Neurology. 8 Supp 1: S28-39, Oct. 1995

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