Screaming in a Patient With Dementia

Authors: 

Melinda S. Lantz, MD

Citation: 

Pages 12 - 15

Case Presentation
Mrs. R is an 84-year-old widowed woman with a 3-year history of dementia of the Alzheimer’s type. She lived in her apartment with part-time home care until 1 year ago, when she started wandering at night and was found by the police several times. Mrs. R moved in with her daughter and her husband, Mrs. and Mr. B. Mrs. R remains fairly stable after an initial period of adjustment. She attends a local senior center that offers a dementia care program and is able to use a senior transportation service. She suffers from hypertension treated with losartan 50 mg and hydrochlorothiazide 25 mg once daily in addition to donepezil 10 mg daily for her dementia. After Mrs. R moves in, her son-in-law is diagnosed with metastatic colon cancer. He undergoes surgery and chemotherapy, and is quite frail and weak. Mr. B requires home care and uses a hospital bed that is brought into the household living room. Mrs. R has always had a good relationship with her son-in-law, but when she sees him sleeping in his hospital bed, she begins screaming “Move, get out, go away, move, get out!” in a perseverative manner. Mrs. B tries to explain that her husband is sick and needs the house to be quiet, but this works only for brief periods of time. The staff at the senior center call Mrs. B to report that Mrs. R has started calling out during activities and lunch, disrupting the program. They try placing Mrs. R at her own table and provide additional attention to her during activities. While this helps for short periods, Mrs. R continues to call out and scream at the senior center and at home.

Mrs. B takes her mother to her primary care physician. He finds her to be in good health, with no signs of any acute medical condition. He prescribes quetiapine 25 mg 3 times per day to help with her screaming. Mrs. R is quiet after taking each dose of quetiapine and sometimes falls asleep, but continues to scream when she is awake. The quetiapine dose is increased to 50 mg 3 times per day. Mrs. R suffers a few falls but continues to scream, and also begins cursing. Trazodone 50 mg twice daily is started. Mrs. R sleeps most of the day, is often incontinent, and is too tired to attend the senior center. She wakes up to eat lunch and then goes back to bed after eating.

Mrs. B feels overwhelmed by the needs of her mother and by her husband’s illness. She is upset that her mother is so heavily sedated, but cannot manage the screaming behavior that occurs whenever her mother is fully awake. Mrs. B’s daughter comes to stay with her. She is very worried about the situation, and arranges to take her grandmother to a psychiatrist recommended by the local chapter of the Alzheimer’s Association.

Discussion
Verbal disruption is one of the most common behavioral disturbances found among patients with dementia.1 This includes shouting, screaming, yelling, calling out, cursing, or using language that creates a disturbance and requires intervention by caregivers.2 Verbal disruption may be predictable or unpredictable. It is often repetitive and perseverative in nature. Over the course of their illness, almost 90% of patients with dementia display some type of verbally disruptive behavior.3 It is a common precipitant to nursing home placement.2

Screaming and other types of verbal disruption occur in patients who suffer from dementias of all types, including Alzheimer’s, vascular, Lewy-body variant, frontotemporal, Parkinson’s disease–related, and the less common entities such as prion diseases, metabolic, and other degenerative disorders.4 While frontal lobe degeneration is associated with significant disinhibited behaviors including verbal disruption and physical aggression, screaming is a distressing behavior that has multiple etiologies. An organized approach to the assessment, evaluation, and treatment of this complex problem is required.5 Verbally disruptive behavior is often associated with other symptoms including depression, anxiety, functional decline, communication difficulties, social isolation, and advanced cognitive impairment.2

Verbal disruption must be considered a symptom, not a diagnosis. There is no one specific recommended treatment. Like all symptoms, careful assessment of the nature of the problem must be performed. It is helpful to utilize a behavioral mapping or daily diary approach to assessment. The caregiver is asked to record when the symptoms occur throughout the day and night, the length of time that each episode lasts, where it occurs, and if any identifiable triggers or precipitants to the behavior can be identified.6 This approach tries to determine when, where, and why the verbal disruption develops. This helps to give the caregiver a greater sense of control over dealing with the behavior, and gives the clinician a pattern to help identify possible causes and interventions.5

A number of factors may contribute to screaming in a patient with dementia2-4 (Table I). Medical conditions including pain, urinary tract infections, constipation, thyroid disease, drug-drug interactions, and any condition that leads to mental status changes in the elderly may lead to verbal disruption in a patient with dementia. As a patient with dementia is often unable to complain of any specific physical complaint, the clinician must perform a thorough medical evaluation, review of medications including both over-the-counter and prescription drugs, and a careful physical examination.1,2 Attention to changes in the psychosocial and environmental situation of the patient, as well as mood symptoms, is vital. Identification of symptoms such as hallucinations or paranoia that are associated with the behavioral disturbance is important for treatment planning.4

The approach to treatment of screaming and other verbally disruptive behaviors must include attention to the environment, psychosocial needs, and activity level of the patient1,3,5,6 (Table II). Goals must be realistic. It may not be possible to eliminate the behavior entirely, but the frequency and intensity of the screaming may be reduced. The patient’s distress should be alleviated. Identification of triggers to the behavior is important, as modifying the patient’s routine may help reduce the disruption. It is important to address the need for companionship, reduce overstimulation, offer food and fluids, and attend to the patient’s need for meaningful activity.5,6 Behavioral and environmental interventions may need to be adjusted over time. If one intervention has little impact, others should be tried and combinations utilized. Maintaining contact with caregivers is important to provide support and encouragement.

Verbally disruptive behavior often occurs in patients who suffer from conditions associated with chronic pain. In addition, depressive features are common. Medication treatment strategies should include addressing any conditions associated with chronic pain, such as arthritis, compression fractures, phantom limb syndromes, and contractures. While some studies have shown the benefits of daily doses of acetaminophen in reducing disruptive behavior and improving socialization among patients with dementia, many patients require additional analgesics.7

The treatment of depression in dementia includes the use of selective serotonin reuptake inhibitors such as citalopram and sertraline.4,8 Other agents may include venlafaxine or mirtazapine. Trazodone has been utilized, but its sedating effects may be a limiting factor. In the absence of psychotic symptoms, antipsychotic agents are of limited benefit in the treatment of verbal disruption. As the case patient illustrates, sedation may result in reduction of the screaming, but can lead to side effects, including falls, fractures, and decline in oral intake. Short-term use of antipsychotic or anxiolytic medications may be useful to help reduce overtly distressing symptoms while behavioral and environmental interventions are being implemented. Maximizing the use of cholinesterase inhibitors and memantine may delay the onset of behavioral disturbances in dementia, although it is unclear if starting these agents after the behavioral disturbances occur will alleviate symptoms.3,4

Caregiver burden and fatigue are extremely common among those who care for patients with verbally disruptive behaviors.1 The overt nature of screaming, yelling, and repetitive speech is often overwhelming. It is important to screen for caregiver burden and offer education and linkage to community support services. Educational materials and referrals to local chapters of the Alzheimer’s Association may be accessed at www.alz.org.

Outcome of the Case Patient
Mrs. R is evaluated by a psychiatrist who is affiliated with a dementia daycare program. She appears nervous and tearful during the interview, and frequently rubs her mouth. Mrs. R pulls at her adult diapers and falls asleep after 15 minutes. Her granddaughter tells the psychiatrist that the family reduced her dose of quetiapine back to 25 mg 3 times per day, but now Mrs. R is less verbal and cries a lot. She still screams at times, and her appetite has been poor. A preliminary treatment plan is developed. Mrs. R is started on citalopram 20 mg daily for her symptoms of depression and tearfulness. She is evaluated by a primary care physician at the daycare center, who finds that she has a urinary tract infection, osteoporosis, and several compression fractures in her lumbar spine. She is started on antibiotics and acetaminophen 1000 mg 4 times daily for pain. Mrs. R is evaluated by a dentist, who finds that she has several teeth in very poor condition with generalized gingivitis that are causing significant distress. She begins on a treatment regime to improve her oral hygiene and comfort. As Mrs. R’s screaming behavior began following the illness of Mr. B and the placement of a hospital bed in the living room, the psychiatrist explores the situation and finds that Mrs. R used to sit by the window where her son-in-law now sleeps. The family decides to rearrange the furniture, and Mr. B’s bed is placed in the dining room. Mrs. R’s favorite chair is placed by the living room window, and she starts quietly sitting there. Her mood improves, and she is no longer tearful. She is able to return to the senior center, but later makes a transition to the dementia daycare center due to her ongoing incontinence and need for more supervision. At times, she still calls out and curses, but usually only when she is hungry or tired.

Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Avenue @ 16th Street 2B49, New York, NY 10003; (212) 420-2457; fax: (212) 420-3936; e-mail: mlantz@chpnet.org.References
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2. Draper B, Snowdon J, Meares S, et al. Case-controlled study of nursing home residents referred for treatment of vocally disruptive behavior. Int Psychogeriatr 2000;12(3):333-344.

3. Barton S, Findlay D, Blake RA. The management of inappropriate vocalization in dementia: A hierarchical approach. Int J Geriatr Psychiatry 2005;20(12):1180-1186.

4. Cummings, JL. Neuropsychiatric and behavioral alterations and their management in moderate to severe Alzheimer disease. Neurology 2005;65(6 suppl 3):S18-S24.

5. Ayalon L, Gum A, Feliciano L, Arean PA. Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: A systematic review. Arch Intern Med 2006;166(20):2182-2188.

6. Cohen-Mansfield J. Nonpharmacologic interventions for persons with dementia. Alzheimer’s Care Q 2005;6(2):129-145.

7. Chibnall JT, Tait RC, Harmon B, Luebbert RA. Effect of acetaminophen on behavior, well-being, and psychotropic medication use in nursing home residents with moderate-to-severe dementia. J Am Geriatr Soc 2005;53(11):1921-1929.

8. Kim KY, Bader GM, Jones E. Citalopram for verbal agitation in patients with dementia. J Geriatr Psychiatry Neurol 2000;13(2):53-55.