Special Circumstances of Persons with Dementia and Agitation in Hospice Care.

Abstract Background Approximately 45% of patients with dementia will experience agitation in the last stages of disease. Furthermore, approximately 35% of patients in the late stages of their lives will present agitation despite being treated with lorazepam, morphine, and atypical antipsychotics. Since agitation is particularly prevalent in hospice care, we estimate that at least 45% of the subjects with dementia in hospice care, or approximately 80,000 individuals a year, will die suffering from symptoms of agitation. Methods Differences between agitation in dementia at different stages of the disease were evaluated. Results Agitation in patients with dementia in the moderate stages of the disease requires the correction of the medical condition that could contribute to the presence of agitation. In hospice care eligible patients with agitation and dementia, these conditions are often untreatable and/or side effects associated with treatment could be more deleterious than the presence of agitation. In the treatment of hospice care eligible patients with agitation and dementia, the main concern is to control symptoms and improve patient’s comfort level while preserving alertness and controlling pain and other symptoms frequently present in terminal patients, including nausea and dyspnea, rather than to uncover and treat the potential underlying cause(s) of the syndrome. In addition, several distinct physiological processes develop both in the CNS and in the periphery during the last few weeks of an individual’s life, including changes in tissue concentrations of glucose, lactate, pyruvate, ATP, ADP, AMP, and phosphocreatine (reflecting brain energy metabolism changes observed during the process of dying and after cardiopulmonary resuscitation). Conclusion Symptoms of agitation in moderate demented patients appear to be biologically and symptomatically different than symptoms of agitation in hospice care eligible patients with dementia. Therefore, the hospice care eligible patients with agitation and dementia need to be better studied and treatments tailored to these specific conditions should be developed.