Verbal Outbursts in a Patient with Dementia

Authors: 

Melinda S. Lantz, MD

Citation: 

Pages 14 - 16

Case Presentation
Mr. M is a 78-year-old male who lives at home with his wife. He suffers from dementia of the Alzheimer’s type that was diagnosed four years ago. Mr. M also has diabetes, hypertension, and coronary artery disease. His medications include metformin 500 mg twice daily, glipizide 5 mg once daily, lisinopril 10 mg once daily, metoprolol 50 mg twice daily, aspirin 81 mg once daily, and donepezil 10 mg once daily. Over the past three to four months, Mr. M has become increasingly resistant to showering and changing his clothes. He also frequently spits out his medications, and his wife is uncertain whether he is really taking them. In order to help with daily care, Mrs. M hired a home health aide for four hours a day three times per week. The aide is able to wash Mr. M in bed and changes his clothes. However, he often yells, curses, and makes loud moaning noises during care.

Mrs. M takes her husband to see his primary care physician. Mr. M is very agitated and restless in the waiting room and starts to call out “Go, go, go,” in a loud voice. The physician sees him quickly and finds that his blood pressure is in good control, and his fingerstick blood sugar is also fine. He tells Mrs. M that her husband’s dementia is progressing and recommends starting memantine 5 mg daily. Mrs. M tells the doctor about the problems her husband is having taking pills. He suggests crushing them and putting them in applesauce. Mr. M starts yelling and making moaning noises. The doctor gives Mrs. M prescriptions for all of Mr. M’s medications and asks her to bring him back in three months.

Mrs. M returns home feeling frustrated. She is trying to keep her husband at home but has recently thought about placing him in a nursing home. She increases the home health aide to seven days per week but is worried about her finances. The home health aide tells her that Mr. M seems to do better in the morning in terms of accepting care and taking his medications, so they start doing as much as possible while the aide is there in the morning hours. Evenings are very difficult, as Mr. M will often call out his wife’s name repeatedly, even when she is sitting next to him, and makes moaning noises or shouts curse words.

Mrs. M takes her husband back to the neurologist who had diagnosed him with dementia four years earlier. Mr. M is very disruptive during the appointment, often calling out and cursing. The neurologist attributes this to his progressive dementia and prescribes trazodone 50 mg twice daily and gabapentin 100 mg three times daily for agitation. Mr. M starts taking the medications in the morning when his home health aide is with him. After one week, he is calmer during the day but still calls out, yells, and curses at night. Also, he is sleeping a great deal during the day and staying up later at night. One night, Mr. M starts walking around the house and suffers a fall in the kitchen, hitting his head on the table. Mrs. M calls 911, and he is taken to the Emergency Room (ER).

Mr. M sustains a laceration to his scalp that requires sutures. He is very disruptive in the ER, cursing, screaming, moaning, and calling out his wife’s name. He is given haloperidol 5 mg by intramuscular injection three times over a one-hour period until he falls asleep. Mrs. M tells the ER staff that she cannot manage him at home and asks for help in finding a nursing home. Consultations are requested with Social Services and Psychiatry.

Discussion
Verbally disruptive behaviors among patients with dementia are common.1 The behaviors include screaming, yelling, cursing, calling out, repeating words and phrases, and making noises that may not include words, such as moaning or whining.2,3 Verbal disruption is a great source of caregiver burden and patient distress.4 Ongoing behavioral problems often result in premature nursing home placement.2-4

The prevalence of verbally disruptive behaviors among patients with dementia is high, with up to 25% of patients living in the community and 50% of those who reside in nursing facilities displaying at least one verbally disruptive behavior.4,5 Verbal disruption is more likely to occur in the later stages of dementia, when the patient is less able to communicate using language and speech.6

Risk factors for the development of verbal disruption include more advanced dementia, hearing loss, multiple chronic medical conditions, and decline in communication skills.4 It is vital that all new verbal disruption be evaluated for an underlying cause, as more than half of the behaviors are likely related to a medical, physical, or care needs problem.3,4,7

Comprehensive assessment of verbally disruptive behavior includes a history both from the patient and the caregivers or other reliable informant. The information should include a clear description of the behavior: temporal onset; course; associated circumstances; and its relationship to key environmental factors, such as caregiver status and recent stressors.3,4 The problem behaviors and symptoms should then be considered in the context of the patient’s family, past, personal, social, and medical history.7

A differential diagnosis of the verbal disturbance should proceed on the basis of findings from the comprehensive geriatric evaluation.3,4 The first step is to decide whether the disturbance is a symptom of a new or a pre-existing medical condition or a medication adverse effect. Disturbances that are new, acute in onset, or evolving rapidly are most often due to a medical condition or medication toxicity.4 A new occurrence of verbally disruptive behavior in a patient with dementia may be the main presenting symptom for many acute conditions such as pneumonia, urinary tract infection, arthritis, pain, angina, constipation, or poorly controlled diabetes mellitus.3,4 Additionally, the need to satisfy basic physical needs such as hunger, thirst, boredom, or fatigue that the patient cannot adequately communicate may precipitate a verbal outburst. Medication toxicity due to new or existing medications might also present as verbally disruptive behavior. Treatment or stabilization of the medical or physical cause is often sufficient to resolve the disturbance.3,4,7 Older adults with dementia may require several weeks longer to recover from routine medical problems than those who are cognitively intact.3

The second step is to consider whether the behavioral disturbance is related to an environmental precipitant.7,8 These include disruptions in routine, time change, changes in the caregiving environment, new caregivers, a new roommate, or a life stressor. Other common environmental precipitants include overstimulation, such as too much noise, crowded rooms, close contact with too many people, and too much time spent out of the familiar environment. Understimulation, including the relative absence of people, spending much time alone, or use of television in place of interpersonal contact, can also be a precipitant. Many verbal outbursts may be reduced or eliminated by correcting an environmental precipitant or alleviating a stressful factor.4,5

Another consideration is whether the disturbance results from stress in the patient-caregiver relationship.3 Caring for patients with dementia is difficult and requires a degree of perseverance that most caregivers are capable of learning if proper guidance and support is provided. Inexperienced caregivers, rigid caregivers, or caregivers who themselves are prone to verbal outbursts will often be contributing to the behavioral disturbance.3-5 Caregiver burden may be a problem both in community settings and in nursing homes.9 It is important for the clinician to assess the level of stress and burden on the caregiver as part of the evaluation of verbally disruptive behaviors. Interventions to improve the patient-caregiver relationship and provide caregiver education and support are a vital part of treatment of verbal outbursts. Providing resources to caregivers, such as referral to support groups and respite services, is often very helpful.7-9

The treatment of verbally disruptive behaviors in dementia may require several interventions applied as part of a comprehensive plan of care. In general, treatment begins with appropriate environmental and caregiver interventions. Nonpharmacologic interventions should always be used as a first-line treatment in the management of verbally disruptive behaviors3-5,7 (Table). The implementation of a daily routine and introduction of meaningful activities is vital.3,4 Patients with dementia may display a reduction in verbal outbursts with the use of music, particularly during meals and bathing, and with light physical exercise or walking. Massage, pet therapy, white noise, videotapes of family, and cognitive stimulation programs may also be helpful.3-5

At the core of treatment is the identification of any possible underlying cause of the behavior change, with the recognition that multiple causes may be occurring concurrently.2,3 First and foremost, managing pain, dehydration, hunger, and thirst is paramount. Consider the possibilities of positional discomforts or nausea secondary to medication effects, as these are common contributing factors.4 Environmental modifications can improve patient orientation. Pleasant lighting, caregiver attentiveness, supportive care, and attention to personal needs are also important aspects of treatment.5,6

If the disturbances persist despite best efforts, pharmacologic interventions may be tried, but the success is limited.3 No agent is approved for the treatment of verbal disruption in dementia, although antidepressants and mood stabilizers have been utilized.3,7 Antipsychotic agents may provide a sedative effect, but given the warnings regarding increased risk of cerebrovascular events and mortality in patients with dementia, they should not be considered without a lengthy discussion with the family regarding the risks and limited benefits.10

Information regarding the management of verbally disruptive behavior in dementia may be downloaded from the Alzheimer’s Association website at www.alz.org.

Outcome of the Case Patient
Mr. M required admission to the hospital after it was found that his blood pressure was very low and his blood sugar was elevated to 360 mg/dL. He underwent a computed tomography scan of the brain, which revealed atrophy and old lacunar infarctions, consistent with his dementia and hypertension. Mr. M was started on insulin to control his blood sugar, and his blood pressure medication was discontinued. The trazodone and gabapentin were also discontinued. The nursing staff noted that Mr. M would often begin yelling and calling out when he was being repositioned or during attempts to move him from the bed to a chair. The issue of pain was raised as a factor in his calling-out behaviors. X-rays of his knees and hips revealed moderate-to-severe osteoarthritis. Mr. M was started on standing doses of acetaminophen 650 mg every 4 hours during the day, with some improvement noted in his calling out and resistance to bathing. An orthopedic consult was performed, and Mr. M was given injections of steroids into his knees. He appeared calmer with this treatment and called out for his wife only a few times. The episodes of cursing, screaming, and moaning rarely occurred.

As Mr. M was reluctant to take pills, his medication regime was minimized during the hospital stay. He no longer required antihypertensive medications and was given one injection daily of a long-acting insulin in place of the metformin and glipizide. His wife was able to administer the insulin. Acetaminophen was changed to liquid form, which Mr. M drank mixed with juice. Donepezil was changed to an orally dissolving tablet that could be placed on his tongue, and memantine was discontinued.

Mr. M was evaluated by the psychiatrist, who found him to be in the severe stage of dementia. He was dependent in all aspects of activities of daily living and was able to speak only a few words in a perseverative and repetitive manner. He was unable to answer any direct questions. He was calm in the presence of his wife but began calling out her name when she briefly left the room. Mr. M appeared to enjoy eating and also was calmer with music playing. He did not display any signs of mood disturbance or psychosis. He smiled at times and appeared to have improved with pain management and minimizing of his medication regime. The psychiatrist suggested that his wife keep a daily log of when Mr. M’s verbal disruptions occurred in order to look for triggers, such as hunger or fatigue, and to plan for offering him comfort measures.

The social worker met with Mrs. M and was able to enroll Mr. M is a homecare program for patients at risk for nursing home placement. The program provided geriatric care management services, which included assistance with bill paying, transportation to medical appointments, and advocacy in obtaining home health aide services. Mr. M was discharged from the hospital after a five-day stay.

At a six-month follow-up visit with the psychiatrist, Mr. M appeared calm. He continued to have periods of calling out for his wife, but these occurred typically in the late afternoon and early evening. His wife felt able to manage these episodes, as she knew when to expect them. A home health aide continued to provide direct care for Mr. M, and with the care management program his wife felt comfortable keeping him at home.

The author reports no relevant financial relationships.

Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: mlantz@chpnet.org.References
1. Delirium, dementia and amnestic and other cognitive disorders. In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000:135-180.

2. Nagaratnam N, Patel I, Whelan C. Screaming, shrieking and muttering: The noise-makers amongst dementia patients. Arch Gerontol Geriatr 2003;36(3):247-258.

3. McMinn B, Draper B. Vocally disruptive behavior in dementia: Development of an evidence based practice guideline. Aging Ment Health 2005;9(1):16-24.

4. Leonard R, Tinetti ME, Allore HG, Drickamer MA. Potentially modifiable resident characteristics that are associated with physical or verbal aggression among nursing home residents with dementia. Arch Intern Med 2006;166(12):1295-1300.

5. Herman RE, Williams KN. Elderspeak’s influence on resistiveness to care: focus on behavioral events. Am J Alzheimers Dis Other Demen 2009;24(5):417-423. Published Online: August 19, 2009.

6. Koopmans RT, van der Molen M, Raats M, Ettema TP. Neuropsychiatric symptoms and quality of life in patients in the final phase of dementia. Int J Geriatr Psychiatry 2009;24(1):25-32.

7. 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.

8. Bourbonnais A, Ducharme F. The meanings of screams in older people living with dementia in a nursing home [published online ahead of print February 2, 2010]. Int Psychogeriatr.

9. Rosen T, Lachs MS, Bharucha AJ, et al. Resident-to-resident aggression in long-term care facilities: Insights from focus groups of nursing home residents and staff. J Am Geriatr Soc 2008;56(8):1398-1408. Published Online: July 15, 2008.

10. Sultzer DL, Davis SM, Tariot PN, et al; CATIE-AD Study Group. Clinical symptom responses to atypical antipsychotic medications in Alzheimer’s disease: Phase 1 outcomes from the CATIE-AD effectiveness trial. Am J Psychiatry 2008;165(7):844-853.

Comments

Thank you for posting this. Currently I am working on a small integrative review on the use of second generation antipsychotics and the incidence of CVEs. It stands that there may not be a risk of CVEs, however, other factors, such as risk and concomitant medication may induce this risk. The reality is that the state of the science is in an infantile stage. Reading this article highlights the importance of psychological, environmental and social interventions to control these symptoms. This is an article I will save for the day when I begin to practice as a geriatric NP. Thank you, J. Dunlap Student Nurse, University of California, Irvine

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