Research on reducing agitation welcome

A DOCTOR WRITES:THE RESULT of Norwegian research suggesting painkillers may reduce agitation in some people with dementia is welcome. Neither doctors nor relatives are comfortable when prescribing for a severely agitated older person, particularly when available agents resemble "chemical coshes" linked to serious side-effects.

The premise for effectiveness of painkillers in this study is that pain is causing agitation in someone unable to explain they are in pain. It is unlikely that paracetamol and other painkillers act directly as sedative agents in patients with dementia.

The study of some 350 residents of nursing homes with moderate or severe dementia showed a 17 per cent fall in symptoms of agitation in those prescribed paracetamol, morphine or buprenorphine for a period of eight weeks.

Dementia is a cluster of symptoms and signs manifested by difficulties in memory, disturbances in language, psychological and psychiatric changes and impairments in activities of daily living. Alzheimer’s is a specific disease entity and is the commonest cause of dementia, accounting for about 50 per cent of cases.

Vascular dementia accounts for about 25 per cent of cases. A further 25 per cent of people with dementia are thought to have a combination of Alzheimer’s and vascular dementia.

Alzheimer’s affects about 6 per cent of over-65s. There are three primary groups of symptoms. A cognitive dysfunction cluster includes memory loss, language difficulties and executive dysfunction. The second group comprises psychiatric symptoms and behavioural disturbances. The third comprises difficulties with activities of daily living.

Some with Alzheimer’s respond to drugs called cholinesterase inhibitors, giving improvement in memory and other symptoms. For someone with vascular dementia, treating blood pressure and diabetes and tackling risk factors for stroke makes sense, although it seems their prevention in the first place offers the best “cure”.

Ongoing research suggests a number of risk factors for dementia. These are not proven causes but rather factors that lead to dementia in a significant number of cases. So quitting smoking, increasing exercise and managing obesity are all likely to cut risk. Keeping the mind active in later life is also important.

Anything that reduces the prescribing of heavy-duty antipsychotic agents in people with marked agitation is helpful. There are caveats: paracetamol is a benign drug in proper dosage, but the use of morphine and other opiates in this trial clouds the result slightly. These patients were all nursing home residents – will painkillers be as effective in those cared for at home?

The role of non-drug treatments for pain and agitation must be clarified before paracetamol or other analgesic agents become first-line treatment for all older people with dementia who may be in pain.