As the prevalence of Alzheimer's disease (AD) increases, concerns have been voiced regarding how to best maintain and treat those affected. Psychiatric symptoms may be a prominent and influencing factor in decisions regarding the most appropriate level of care. The behavioral manifestations of AD, particularly agitation, may present dilemmas for formal and informal caregivers. The most significant dilemmas surrounding appropriate care for individuals manifesting psychiatric symptoms and negative behaviors may include the safety of caregivers as well as the safety of the diagnosed individual. These dilemmas may be compounded when there is not adequate psychiatric/psychotherapeutic intervention. This paper will seek to examine the psychopathology associated with AD as well as some intensive and restrictive interventions available to formal and informal caregivers when less intensive and less restrictive interventions fail. The intensive and restrictive interventions discussed include institutionalization, physical and chemical restraints, and psychiatric hospitalization.
References
1.
Cohen D , Eisdorfer C, Corelick P, et al: Sex differences in the psychiatric manifestations of Alzheimer's disease. Journal of the American Geriatrics Society. 1993; 41(3): 229-232.
2.
Kaplan HI , Sadock BJ: Synopsis of psychiatry.8th ed.Baltimore, MD: Williams & Wilkins, 1998.
3.
Crook T : Dementia. In LL Carstensen, BA Edelstein (Eds.): Handbook of clinical gerontology. New York: Pergamon Press, 1987; 96-111.
4.
Walker RJ , Pomeroy EC, McNeil JS, Franklin C: Anticipatory grief and Alzheimer's disease: Strategies for intervention. Journal of Gerontological Social Work. 1994a; 22(3/4): 21-39.
5.
Kapust LR : Living with dementia: The ongoing funeral. Social Work in Health Care.1982; 7(4): 79-91.
6.
Author : Diagnostic and statistical manual of mental disorders.4thed.Washington, DC: American Psychiatric Association, 1994.
7.
Feil N : The validation breakthrough. Baltimore, MD: Health Professions Press, 1993.
8.
Reisberg B , Ferris SH, de Leon MJ, Crook T: The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry. 1982; 139: 1136-1139.
9.
Sultzer DL , Levin HS, Mahler ME, et al: A comparison of psychiatric symptoms in vascular dementia and Alzheimer's disease. American Journal of Psychiatry. 1993; 150(12): 1806-1812.
10.
Lachs MS , Becker M, Siegal AP, et al: Delusions and behavioral disturbances in cognitively impaired elderly persons. Journal of the American Geriatrics Society. 1993; 40 (8): 768-773.
11.
Rubin EH , Kinscherf BA, Morris JC: Psychopathology in younger versus older persons with very mild dementia of the Alzheimer's type. American Journal of Psychiatry. 1993; 150(4): 639-642.
12.
Rubin EH , Kinscherf BA: Psychopathology of very mild dementia of the Alzheimer's type. American Journal of Psychiatry. 1989; 146 (8): 1017-1021.
13.
Coolidge FL , Burns EM, Nathan JH, Mull CE: Personality disorders in the elderly. Clinical Gerontology. 1992; 12(1):41-55.
14.
Chatterjee A , Strauss ME, Smyth KA, Whitehouse PJ: Personality changes in Alzheimer's disease. Archives of Neurology. 1992; 49(5): 486-491.
15.
Seltzer B , Larkin JP, Fabiszewski KJ: Management of the outpatient with Alzheimer's disease: An interdisciplinary approach. In L Volicer, KJ Fabiszewski, YL Rheaume, KE Lasch (Eds.): Clinical Management of Alzheimer's Disease. Rockville, MD: Aspen Publications, Inc., 1988.
16.
Rovner BW , Broadhead J, Spencer M, et al: Depression and Alzheimer's disease. American Journal of Psychiatry. 1989; 146 (3): 350-353.
17.
Teri L , Reifler BV: Depression and dementia. In LL Carstensen, BA Edelstein (Eds.): Handbook of clinical gerontology. New York: Pergamon Press. 1987; 112-119.
18.
Pearlson GD , Ross CA, Lohr WD, et al: Association between family history of affective disorder and the depressive syndrome of Alzheimer's disease. American Journal of Psychiatry. 1990; 147(4): 452-456.
19.
Baker FM , Miller CL: “Cocooning” A clinical sign of depression in geriatric patients. Hospital and Community Psychiatry. 1991; 42(8): 845-846.
20.
Cohen GD : Prevalence of psychiatric problems in older adults. Psychiatric Annals. 1990; 20(8): 433-438.
21.
Aronson MK : Overview of dementia and the nursing home. In MK Aronson (Ed.): Reshaping dementia care Practice and policy in long-term care. Thousand Oaks, CA: Sage Publications, 1994a; 1-14.
22.
Bliwise DL : What is sun downing?Journal of the American Geriatrics Society. 1994; 42(9): 1009-1011.
23.
Whall AL , Gillis GL, Yankou D, et al: Disruptive behavior in elderly nursing home residents: A survey of nursing staff. Journal of Gerontological Nursing. 1992; 18(10): 13-17.
24.
Lukovits TG , McDaniel KD: Behavioral disturbance in severe Alzheimer's disease: A comparison of family member and nursing staff reporting. Journal of the American Geriatrics Society. 1992; 40(9): 891-895.
25.
Cohen-Mansfield J , Marx MS, Rosenthal AS: A description of agitation in a nursing home. Journal of Gerontology. 1989; 44(3): 77-84.
26.
Ryan DP , Tainsh SM, Kolodny V, et al: Noise-making amongst the elderly in long term care. The Gerontologist. 1988; 28(3): 369-371.
27.
Seltzer B , Buswell A: Psychiatric symptoms in Alzheimer's disease: Mental status examination versus caregiver report. The Gerontologist. 1994; 34(1): 103-109.
28.
Dunkelman D , Dressel RC: The nursing home environment and dementia care. In MK Aronson (Ed.): Reshaping dementia care Practice and policy in long-term care. Thousand Oaks, CA: Sage Publications, 1994; 60-68.
29.
Cohen-Mansfield J , Besansky J, Watson V, Bernhard LJ: Underutilization of adult day care: An exploratory study. Journal of Gerontological Social Work. 1994; 22(1/2): 21-39.
30.
Dieckman DM , Zarit SH, Zarit JM, Gatz M: The Alzheimer's disease knowledge test. The Gerontologist. 1988; 28(3): 402-407.
31.
Braun KL , Takamura JC, Forman SM, et al: Developing and testing outreach materials on Alzheimer's disease for Asian and Pacific Islander Americans. The Gerontologist. 1995; 35(1): 122-126.
32.
Ballard EL , Nash F, Raiford K, Harrell LE: Recruitment of black elderly for clinical research studies of dementia: The Cerad experience. The Gerontologist. 1993; 33(4): 561-565.
33.
Cox C : Comparing the experiences of black and white caregivers of dementia patients. Social Work. 1995; 40(3): 343-350.
34.
Ginther SD , Webber P, Fox PJ, Miller L: Professional allocations of counseling services to persons with Alzheimer's disease: An exploration. Social Work in Health Care. 1993; 19(2): 99-114.
35.
Ginther SD , Webber P, Fox PJ, Miller L: A preliminary study of medical services for persons with Alzheimer's disease: Recommendations by California's Alzheimer's diagnostic and treatment program staff. Journal of Gerontological Social Work. 1994; 21(3/4): 27-49.
36.
Gatz M , Smyer MA: The mental health system and older adults in the 1990's. American Psychologist. 1992; 47(6): 741-751.
37.
Gatz M , Pearson CG: Ageism revised and the provision of psychological services. American Psychologist. 1988; 43(3): 184-188.
38.
Somers FP : Long-term care and federal policy. The American Journal of Occupational Therapy. 1991; 45(7): 628-635.
39.
Kane M : Social work students' willingness to work with elders with Alzheimer's disease. Journal of Social Work Education, In Press.
40.
Chrisman M , Tabar D, Whall AL, Booth DE: Agitated behavior in the cognitively impaired elderly. Journal of Gerontological Nursing. 1991; 17(12): 9-13.
41.
Hussian RA : Wandering and disorientation. In LL Carstensen, BA Edelstein (Eds.): Handbook of clinical gerontology. New York: Pergamon Press, 1987; 177-189.
42.
Algase DL : A century of progress: Today's strategies for responding to wandering behavior. Journal of Gerontological Nursing. 1992; 18(11): 28-34.
43.
Miller TP , Tinkleberg JR, Brooks JO, et al: Selected psychiatric symptoms associated with rate of cognitive decline in patients with Alzheimer's disease. Journal of Geriatric Psychiatry and Neurology. 1993; 6(4): 235-238.
44.
Hasselkus BR : The meaning of activity: Day-care for persons with Alzheimer's disease. American Journal of Occupational Therapy. 1992; 46(3): 199-206.
45.
Aronson MK : Strategies for management of behavioral problems. In MK Aronson (Ed.): Reshaping dementia care Practice and policy in long-term care. Thousand Oaks, CA: Sage Publications, 1994b; 81-93.
46.
Moody HR : The cost of autonomy, the price of paternalism. Journal of Gerontological Social Work. 1998; 29(2/3): 111-127.
47.
Kane R : Long-term care. In National Association of Social Workers (Ed.): Encyclopedia of social work. Silver Spring, MD: NASW Press, 1987; 59-72.
48.
Steele C , Rovner B, Chase GA, Folstein M: Psychiatric symptoms and nursing home placement of patients with Alzheimer's disease. American Journal of Psychiatry. 1990; 147(8): 1049-1051.
49.
Kunik ME , Yudofsky SC, Silver JM, Hales RE: Pharmacologic approach to management of agitation associated with dementia. Journal of Clinical Psychiatry.1994; 55(2 suppl.): 13-17.
50.
Moak GS : Characteristics of demented and nondemented geriatric admissions to a state hospital. Hospital and Community Psychiatry. 1990; 41(7): 799-801.
51.
Pillemer K , Moore DW: Abuse of patients in nursing homes: Findings from a survey of staff. The Gerontologist. 1989; 29(3): 314-320.
52.
Teresi JA , Holmes D, Monaco C: An evaluation of the effects of co-mingling cognitively and noncognitively impaired individuals in long-term care facilities. The Gerontologist. 1993; 33(3): 350-358.
53.
Sloane PD , Lindeman DA, Phillips C, et al: Evaluating Alzheimer's special care units: Reviewing the evidence and identifying potential sources of study bias. The Gerontologist. 1995; 35 (1): 103-111.
54.
Grant LA , Potthoff SJ: Separating the demented and cognitively intact: Implications for activity programs in nursing homes. Journal of Mental Health and Aging. 1997; 3: 183-193.
55.
Grossman HD , Weiner AS, Salamon MJ, Burros N: The milieu standard for care of dementia in a nursing home. Clinical Gerontologist. 1986; 6: 73-89.
56.
Rose JH : A life course perspective on health threats in aging. Journal of Gerontological Social Work. 1991; 17(3/4): 85-97.
57.
Salamon MJ : Criterion for psycho-geriatric placement in a skilled nursing facility. Clinical Gerontologist. 1986; 6(1): 21-33.
58.
Peppard NR : Special nursing home units for residents with primary degenerative dementia: Alzheimer's disease. Journal of Gerontological Social Work. 1986; 9(2): 5-13.
59.
Mintzer JE , Lewis L, Pennypaker L, et al: Behavioral intensive care unit (BICU): A new concept in the management of acute agitated behavior in elderly demented patients. The Gerontologist. 1993; 33(6): 801-806.
60.
Grant LA : Beyond the dichotomy An empirical typology of Alzheimer's care in nursing homes. Research on Aging. 1998; 20(5): 569-592.
61.
Sand BJ , Yeaworth RC, McCabe BW: Alzheimer's disease special care units in long-term care facilities. Journal of Gerontological Nursing. 1992; 18(3): 28-34.
62.
Koren MJ , Guastadisegni P, Aronson MK: Reimbursement issues and the future direction of nursing home care for persons with dementia. In MK Aronson (Ed.): Reshaping dementia care Practice and policy in long-term care. Thousand Oaks, CA: Sage Publications, 1994; 145-160.
63.
Exum ME , Phelps BJ, Nabers KE, Osburne JG: Sundown Syndrome: Is it reflected in the use of PRN medications for nursing home residents?The Gerontologist. 1993; 33(6): 756-761.
64.
Risse SC , Barnes R: Pharmacologic treatment of agitation associated with dementia. Journal of the American Geriatrics Society. 1986; 34: 368-376.
65.
Grossberg GT : Psychiatric symptoms of Alzheimer's disease Focus on agitation and aggression. Alzheimer's Disease Management Today. 1998; 1(1): 4-7.
66.
Bruno R : Policy for the people: One facility's introduction to restraint reduction. Journal of Gerontological Social Work. 1994; 22(3/4): 129-142.
67.
Cox-Post D , Krasnausky P, Grossman HD, Lynch D: The reduction of restraint use in the nursing home. In MK Aronson (Ed.): Reshaping dementia care Practice and policy in long-term care. Thousand Oaks, CA: Sage Publications, 1994; 94-108.
68.
Marin DB , Greenwald DS: Carbamezapine for aggressive agitation in demented patients during nursing care. American Journal of Psychiatry. 1989; 146: 805-805.
69.
Pinner E , Rich CI: Effects of trazodone on aggressive behavior in seven patients with organic mental disorder. American Journal of Psychiatry. 1988; 145: 1295-1296.
70.
Birkett DP : Psychiatry in the nursing home. New York: The Haworth Press, 1991.
71.
Ponce H , Molinari V, Kunik ME, et al: Placement predictors of geropsychiatric inpatients: Home versus nursing home. Journal of Gerontological Social Work. 1998; 29(4): 3-12.
