Dementia and Anti-Psychotic Medications: A Screening Tool to Decrease Likelihood of Aggression in Hospital Settings

Background and Purpose:

Nearly a quarter of acute hospital beds are occupied by victims of Alzheimer’s disease or other dementias (ADOD), although admissions are usually for unrelated reasons. Improving healthcare services and outcomes for these patients is a policy and clinical priority. Among the challenges of treating individuals with ADOD is the presence of behavioral and psychological symptoms of dementia (BPSD), which might include aggression or agitation. BPSD is problematic both because of risk to patients and caregivers, as well as the increased likelihood of institutionalization after incidents of aggressive behavior. Study objective:Screening mechanisms that could identify patients with increased risk at intake would provide opportunities to address modifiable factors in the environment to lower risk for these patients. We hypothesized that there would be a correlation between incidents of aggression while inpatient and factors such as delirium or being on a psychiatric medication at intake.

Methods:

Using the EMERSE search tool, we searched the electronic medical records of adults aged 60+ who spent at least 24 hours at the hospital in any area except the psychiatric unit during a one year study time frame (N=5,008). We completed two independent searches for incidents of dementia and incidents of physical aggression, then cross-searched and manually searched for incidents of delirium and medications at intake. Analyses included only adults with ADOD (n=505), which included 120 individuals who were aggressive during their stay. Stepwise logistic regressions and chi-squared analyses were used to examine relationships between aggressive behavior and demographics, delirium, and/or whether there was a psychiatric medication at intake.

Results:

Inviduals taking a psychiatric medication at intake were disproportionately female (X²=4.8, p=.03), white (X²=5.5, p<.02), and were more likely to enact aggression during their hospital stay (X²=12.4, p<.001). Interaction between delirium and psychiatric medication at intake significantly related to incidence of aggression (p=.013), and there were significant main effects for both medication at intake (p<.001) and delirium status (p=.014). Data suggest that there is a relationship between delirium at intake and aggression, or being on a psychiatric medication at intake and aggression, and that the presence of psychiatric medications at intake may moderate the effect of aggression risk associated with delirium. Among those who did not have delirium at admit, patients who were prescribed psychiatric medications were more likely to be aggressive than those who were not on psychiatric medication (p<.001). Results suggest that psychiatric medications increase risk of aggressive behavior among individuals with ADOD who did not have delirium, but had no affect on aggression risk among those who did have delirium.

Implications:

Through examination of a one-year cross-section of records, we identified several consistent patterns. Individuals who demonstrated aggressive behaviors were more likely to have a delirium at intake. Additionally, and more easily identified in the fast-paced environment of an emergency department, being on an antipsychotic medication at intake, for whatever reason, is correlated to aggression. Identifying this risk at intake would provide an opportunity to modify interactions and environmental factors, and lower the risk of aggressive behaviors proactively.