Impact of standardizing care for agitation in dementia using an integrated care pathway on an inpatient geriatric psychiatry unit

Abstract

Objectives: This study examined the effectiveness of an integrated care pathway (ICP), including a medication algorithm, to treat agitation associated with dementia. Design: Analyses of data (both prospective and retrospective) collected during routine clinical care. Setting: Geriatric Psychiatry Inpatient Unit. Participants: Patients with agitation associated with dementia (n = 28) who were treated as part of the implementation of the ICP and those who received treatment-as-usual (TAU) (n = 28) on the same inpatient unit before the implementation of the ICP. Two control groups of patients without dementia treated on the same unit contemporaneously to the TAU (n = 17) and ICP groups (n = 36) were included to account for any secular trends. Intervention: ICP. Measurements: Cohen Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory Questionnaire (NPIQ), and assessment of motor symptoms were completed during the ICP implementation. Chart review was used to obtain length of inpatient stay and rates of psychotropic polypharmacy. Results: Patients in the ICP group experienced a reduction in their scores on the CMAI and NPIQ and no changes in motor symptoms. Compared to the TAU group, the ICP group had a higher chance of an earlier discharge from hospital, a lower rate of psychotropic polypharmacy, and a lower chance of having a fall during hospital stay. In contrast, these outcomes did not differ between the two control groups. Conclusions: These preliminary results suggest that an ICP can be used effectively to treat agitation associated with dementia in inpatients. A larger randomized study is needed to confirm these results.

Welcoming treatment algorithms for agitation in persons living with dementia, 27 years on

“…It is not surprising, therefore, that in 2023 clinicians still welcome these algorithms (Jeste, 2022), the efficacy of which has been established in a small pilot study focusing on outcomes such as earlier discharge from hospital, reduced psychotropic polypharmacy and falls (Kumar et al, 2022). Importantly, Cummings et al (this issue) have recognized the importance of tailoring the intervention to the setting, whether it be the person's home, residential care, the emergency department, or hospice setting.…”

“…It is not surprising, therefore, that in 2023 clinicians still welcome these algorithms (Jeste, 2022), the efficacy of which has been established in a small pilot study focusing on outcomes such as earlier discharge from hospital, reduced psychotropic polypharmacy and falls (Kumar et al ., 2022). Importantly, Cummings et al .…”

Pharmacotherapy in geriatric psychiatry: what we know and what we need to know

“…Practicing clinicians will welcome an algorithm for treating older people with neuropsychiatric or behavioral symptoms associated with dementia. Kumar et al (2022) conducted a pilot study that built on an algorithm proposed by Davies, et al (2018) and implemented it as part of an Integrated Care Pathway for patients with Alzheimer's or mixed dementia, admitted to an inpatient geriatric psychiatry unit for management of agitation or aggression. The protocol starts with a thorough medical and psychiatric work-up to determine usefulness of individualized nonpharmacological and pharmacological interventions the patient is receiving, and tapering off ineffective medications that were being used for managing behavioral symptoms.…”

Ending choose-your-own-adventure care for agitation in dementia

“…In this issue of the journal, Kumar et al (2022) have built on this algorithm and implemented it as part of an integrated care pathway (ICP) for patients with Alzheimer's or mixed dementia admitted to an inpatient geriatric psychiatry unit for management of agitation or aggression. As enacted by their team, patients first received a thorough medical and psychiatric workup to address potential underlying conditions.…”