Aggression in Elderly Patients with Dementia
Dementia is a brain disorder which manifests with clinical deficits in two or more areas of cognition which are of enough magnitude to significantly affect basic and necessary activities of daily living. Impairments typically present with memory loss and difficulties with executive function, judgment, insight, abstract thinking, visualspatial ability or language dysfunction which occurs in the context of a decline from a previous higher level of functioning [48]. The prevalence of cognitive impairment in large, community-based studies is 2.9% in the age group of 65 to 74, 6.8% in the range from 75 to 84 and 15.8% from age 85 and older [49]. Another study reported the prevalence of Alzheimer’s dementia in the community aged 65 and older to be 10.3%, and in addition, the prevalence appears to increase by age group, with 3% in the age group 65 to 74, 18.7% in the age group 75 to 84 and 47.2% in the age group 85 and older [49, 50]. Thus, it might be anticipated that as the general population ages, the population of those with dementia will continue to grow.
Approximately, 67% of dementias are of the Alzheimer’s type followed by Vascular dementia which constitutes 15% to 25% of dementia syndromes. Lewy Body dementia comprises about 10% of dementia cases [48]. There are many less common degenerative brain disorders which manifest as dementia which include the parkinsonian dementias, as well as frontal dementias with prefrontal executive dysfunction as an earlier feature. Very rapidly progressing frontal dementias include Pick’s Disease and Creutzfeldt-Jacob Disease [51].
It has been reported that 60% of individuals with dementia living in the community have manifested behavioral or psychiatric disturbances [52, 53]. In the nursing home population, 80% of elderly with dementia exhibit psychiatric or behavioral findings [54, 55]. Lifetime risk of psychiatric symptom or behavioral disturbances in the elderly with dementia is reported to reach 100% [53].
Agitation and aggression are relatively common in demented populations, particularly in the content of psychotic symptoms. Zimmer [4] reported that physical and verbal agitation was seen in 86% of demented elderly and was largely associated with bathing and toileting care, which can result in frequent injury to care giver staff [56]. In general, the prevalence of agitation in dementia is reported to range from 20% to 80% [57-59].
Physical aggression among community- living individuals with dementia occurs in the order of 11% to 46% [58]. Physical aggression can be manifested in association with mood disturbances, cognitive compromise, psychosis or combinations of these phenomena [60]. In Alzheimer’s disease, major depression has a prevalence rate of 24% contrasted to 7% in similar populations without dementia [61]. Psychosis presents with delusions or hallucinations in Alzheimer’s disease [62]. It has been reported that the prevalence of delusions in Alzheimer’s disease ranges from 9% to 63% with a median of 36% [58]. Hallucinations in Alzheimer’s disease are reported to occur at rates of 4% to 41% with a median of 18% [58, 63].
Progressive dementia generally leads to more severe behavioral disturbance, aggression and progressively worsening clinical outcomes. It is known that psychotic features and agitation are associated with decreased quality of life in the elderly [64, 65], and rapidly deteriorating cognitive functioning is associated with more severe psychosis [66-68]. Overall, it has been reported that behavioral disturbances in dementia decrease survival [58, 69].
In addition to profoundly destructive effects on the individual, psychosis and agitation with dementia cause substantial caregiver distress [70-74]. Caregiver burden and behavioral disturbances increase the likelihood of nursing home placement [75]. Additionally, behavioral disturbances in dementia are associated with increased healthcare costs [76].
Management of Behavioral Symptoms of Dementia
Both behavioral and neuropsychopharmacological approaches have been applied to manage behavioral disturbances in dementia in elderly individuals. The Omnibus Budget Reconciliation Act (OBRA) of 1987 mandates behavioral management prior to the use of physical or chemical restraints [77]. Behavioral approaches to aggression in institutional care include differential reinforcement of alternative behaviors [77-79]. Limitations in these approaches among individuals with severe memory and cognitive deficits have prompted other approaches including non-contingent reinforcement to treat behavioral disturbances in elderly using a time- based method of reinforcement [77]. This technique has the advantage of higher reinforcement, ease of implementation and rapid response [77]. Other therapies that may hold promise include cognitive stimulation therapy, music therapy and educational approaches [58]. Studies [80, 81] have demonstrated reduced antipsychotic use and reduced behavioral disturbances [82] with educational approaches [58]. Nevertheless, the evidence for the overall effectiveness of psychosocial approaches has, in general, been equivocal [58, 83, 84].
Although behavioral approaches should be a starting point in the management of aggression in the elderly with dementia, pharmacological interventions are indicated when the response to behavioral disturbances is limited. Medication management, sometimes viewed as a "chemical restraint", is the most common approach to aggression and agitation in nursing homes [85]. A more recent report notes that 40% to 50% of residents of nursing homes are treated with psychotropic medications affecting resident ambulation [86]. Even so, the inappropriate excessive use of antipsychotics, sedative hypnotics and anxiolytic to sedate patients has decreased since the implementation of the Nursing Home Reform Act contained in OBRA 87 [87]. Four principal classes of agents used in the management of behavioral disturbances in the elderly with dementia include the cognitive enhancers, antidepressants, anticonvulsants, and the antipsychotics.
The use of pharmacological interventions, particularly the antipsychotics, are widely used [58]. In general, antipsychotics—particularly aripiprazole, olanzapine, quetiapine, risperidone and haloperidol, have been found in the literature to have modest effectiveness compared to placebo [58]. At the same time the literature currently indicates a higher incidence of mortality, 1% to 2% over 8 to 12 weeks, associated with treatment with atypical antipsychotics as a class [58]. The risks for cardiovascular adverse events and death after 8 to 12 weeks of antipsychotic treatment are unclear [58]. As a result this has lead to an FDA warning for atypical antipsychotics and an increased risk of stroke and adverse cardiovascular events. There have been a paucity of studies looking at comparing the typical and atypical antipsychotics which showed comparable efficacy in most studies and greater efficacy of the atypical antipsychotics in only one study [58]. However, in one study typical antipsychotics have also been reported to have a higher risk of death compared to atypical antipsychotics [58, 88]. The atypical antipsychotics, in addition, were found to be less likely to cause involuntary movement disturbances including dyskinesias and dystonias in individuals with dementia compared to typical antipsychotics [58]. Particularly, high potency typical antipsychotics are most likely to be associated with involuntary movement disturbances in the elderly [58].
The cognitive enhancers include the cholinesterase inhibitors (galantamine, rivastigmine, donepezil) and the NMDA-acting drug memantine. Efficacy of these agents in the treatment of behavioral disturbances in the elderly with dementia appear to be modest, at best, with their overall effectiveness unresolved [58, 89, 90].
Serotonin antidepressants including trazodone and the selective serotonin reuptake inhibitors may diminish aggression and agitation in a subset of elderly individuals with dementia [91-96]. The anticonvulsants have had a spectrum of reports demonstrating limited to no benefit in a subset of elderly with dementia and agitation/aggression [96-99].
With regard to the use of benzodiazepines in elderly populations with dementia, the results have been equivocal relative to therapeutic efficacy and tolerablity [58]. Of concern are reports linking benzodiazepine use and falls in the elderly [100, 101].
Overall, none of the classes of psychotropic agents nor psychosocial approaches have clearly established superior effectiveness in treating agitation and aggression in dementia [58]. All of the currently available psychotropic agents have been employed to treat other illnesses, and then their application has been extrapolated to address symptom complexes of dementia. Currently there are no specifically targeted agents for the aggressive and agitated features of dementia [58]. At the same time, the available psychotropic agents carry newly recognized risks that need to be weighed against unclear benefit. Current clinical practice requires balancing these putative unestablished benefits with known risks in the context of a thoughtful, transparent consenting process with family and patient.
Aggression in Elderly Patients with Mood, Anxiety and Primary Psychotic Disorders
Depression, mania, anxiety and primary psychotic illness (such as schizophrenia) at times are associated with agitation, and there is a generally positive relationship between the severity of depression and the level of agitation. As a possible explanation for this overlap, a model of based upon brain neurotransmitters, specifically serotonergic sensitivity, has been proposed [15]. The serotonergic sensitivity model has two types,1) a serotonin- sensitive model with manic symptoms and impulsive aggression and, 2.) a serotonin- resistant model with different agitated behaviors [15]. Stahl [102] has proposed the serotonin (5HT1) a receptor as one of the "links" between these effects on emotion and behavior. Additional possible links involve other neurotransmitters such as GABA and noradrenergic transmission. These mechanisms may explain why serotonergic antidepressants drugs (SSRIs such as fluoxetine) and other serotonergic compounds (azapirones) may reduce levels of aggression/agitation.
Older patients with depression, mania, severe anxiety or psychosis may have symptoms of agitation with differing components. This can be aggressive physical behavior such as fighting, grabbing, destroying things, or aggressive verbal behavior such as cursing and screaming. Non-aggressive physical behaviors include pacing, and non-aggressive verbal behavior includes constant or repetitive questioning. These symptoms are generally more frequent and prominent when individuals have cognitive impairment [60] due to inability to analyze the environment or feelings experienced during stress.
Geriatric Mood, Anxiety and Primary Psychotic Disorder: Prevalence and Symptoms
Depression
Geriatric depression is a growing problem which is under-recognized and under-treated. It has been estimated that the prevalence of major depression in the general population is 12% with depressive symptoms affecting as much as 15% of older persons [103]. Major depression is one of the leading causes of disability in adults, and in the elderly may have an additive effect to medical illnesses creating an increase in morbidity, mortality and placement in nursing homes. Late- life depression is a heterogeneous syndrome that may occur in the context of cognitive impairment, structural brain abnormalities, and other psychiatric and medical comorbidities which are frequently associated with poor treatment responses. Medical comorbidities are very common among older adults with depression and are risk factors for the development or worsening of depression, with depression itself being a risk factor for medical illnesses. Depression plus physical problems leads to increased morbidity, high levels of disability with frequent hospitalizations and nursing home placement and an increase in mortality. Currently there is substantial literature documenting the complex relationship between depression, cardiovascular and cerebrovascular disease, with evidence that depression is associated with a greater number of re-hospitalization days after angioplasty or myocardial infarction [104, 105]. Also 20-30% of patients develop depression after stroke with left- sided stroke more likely to be associated with early- onset depression [106].
The diagnosis of depression relies heavily on somatic such as changes in sleep, weight, appetite, levels of energy and psychomotor activities. These symptoms can be caused by medical (non-psychiatric) comorbidities making them "exclusionary" criteria for the diagnosis. In these cases it is important to pay attention to the "psychological" symptoms such as sadness, unhappiness, inability to enjoy things (anhedonia), isolation, irritability, anger and delusions/hallucinations. A challenge in the evaluation of geriatric patients with mood disorders is the patient who appears to be suffering a depressive syndrome but denies that s/he is depressed, creating a "clinical" diagnosis of "masked" depression. Aggressive behavior is most generally seen in individuals with the more severe types of depression, but as noted previously are amplified when dementia or cognitive impairment is present.
Bipolar Disorders
Elderly patients with bipolar disorders represent 5-19% of the patients presenting for acute treatment within geriatric psychiatric services [107]. These patients represent a mixed and complex set of patients with frequent comorbidities, poor outcomes and in many cases, high morbidity and mortality rates.
It has been generally accepted that the type and range of manic symptoms in the elderly are similar to the general population but with a tendency to be of lesser severity and intensity. Co-existing symptoms of depression and mania are fairly common in bipolar elders with increasing symptoms of irritability or aggression corresponding to increased illness severity. Some patients have "mixed" presentations with manic symptoms and perceptual abnormalities such as delusions and hallucinations. Some patients will show "dis-inhibition" symptoms such as pathological laughing with lesions of the right side of the brain and pathological crying with lesions on the left side. Secondary manias (mania associated with medical or neurological disease) are associated with other behavioral or physical symptoms indicating head injuries, alcoholism, tumors, endocrine disorders, AIDS, silent cerebral infarctions, medications and multiple sclerosis.
Anxiety Disorders
The prevalence rates for anxiety disorders in older adults range from 3.5% to 10.2% suggesting a higher prevalence than late-life depression with increased incidence among those who are home-bound, living in a nursing home or those with other comorbidities. The prevalence of anxiety symptoms may be as high as 20% [108]. Generalized anxiety disorder (GAD) is highly prevalent in the elderly, with a reported rate of 7.3% . Panic disorders have a prevalence rate of 0.1-1%. Phobias range from 3.1% to 12%. Older patients with anxiety disorders report similar symptoms as do younger patients, but with the confounding situation of comorbid medical conditions. Patients suffering anxiety disorders may have a series of "physical" symptoms which in many cases are the symptoms causing the patient to seek medical help. Somatic symptoms such as tachycardia, chest tightness, vertigo, tremors, sweating, dizziness, paresthesias are common in medical and anxiety problems. Aggression is uncommon with anxiety disorders unless overall illness severity is relatively high.
Schizophrenia
Most individuals with schizophrenia first develop the illness in young adulthood, although it is known that some individuals experience a later-onset form (sometimes called "paraphrenia") after age 45 or beyond. Thus older adults with schizophrenia comprise individuals with illness of varying duration and time of onset. In the large scale
Epidemiological Catchment Area (ECA) survey of psychopathology in the United States general population, the reported 1 year prevalence rates for schizophrenia were 0.6% for people aged between 45 and 64 and 0.2% for those over 65 years [109]. A review done by Harris and Jeste [110] reported that 23.5% of patients with schizophrenia had an onset after the age of 40 with 3% after the age of 60. In several studies reported between 1955 and 1993 it was found that the frequency of late-onset schizophrenia among patients in psychiatric facilities had a range from 3 to 10% [111, 112].
The older person who develops psychotic symptoms represents a diagnostic and management dilemma for the clinician. The aging process is a risk factor for the development of psychosis, and if the patient presents cognitive deficits it is difficult to determine if the psychotic symptoms are part of a dementia process or a primary psychotic disorder such as schizophrenia. Patients with late-onset schizophrenia show a generalized pattern of cognitive deficits that are similar to the patterns of young patients with schizophrenia, but different from cognitive deficits in patients with dementia of the Alzheimer type, with the schizophrenia patents generally preserving their learning capacity.
Delusions are the most common presenting symptom of late-onset schizophrenia. Persecutory delusions are most frequent but other delusions are not uncommon. Howard et al [113] reported delusions of reference in 76% of elderly patients, noting that auditory hallucinations are common while formal thought disorders and negative symptoms are uncommon. Arango et al [114] reported that schizophrenic patients posing the greatest risk for violent behavior appear to be those who show suspiciousness and hostility, have more severe hallucinations, show less insight into their delusions, experience greater thought disorder and have poorer control of their aggressive impulses.
Treatment of Elderly Populations with Mood, Anxiety and Primary Psychotic Disorders
If a patient suffers an affective disorder it has to be determined if the agitation is caused by a unipolar depression or a bipolar disorder. This differentiation is easy to make in some situations but it becomes more difficult when the diagnosis under consideration is a psychotic depression or an agitated depression. A psychotic depression is defined as the occurrence of delusions or hallucinations in the setting of a major depressive disorder and may occur in as much as 15% of all depressed patients. Patients with agitated depression have increased psychomotor activity and may exhibit pacing, hand wringing, nail biting, hair pulling, incessant smoking, and incessant talking. A similar situation can happen with patients suffering an exacerbation of symptoms of a schizophrenic disorder. The first step in dealing with these patients is to ensure the safety of the individual and those around them. Patients in these conditions should be approached in a non-threatening matter, if necessary with a show of force provided by trained personnel. The cautious use of sedation with intramuscular (IM) medication and seclusion and/or physical restraints may be necessary to guarantee the safest setting in which to administer evaluation and treatment.
In cases of severe agitation the use of antipsychotic medication continues to be the first line of treatment despite the "black box" warning in the manufacturer’s package insert added to all antipsychotic (conventional and atypical) specifying the "Iincreased risk of mortality in elderly patients treated for dementia-related psychosis" [115]. A meta-analysis done by Schneider [116] (in elderly with dementia) compared seven studies done between 1966 and 1989 resulting in improvement of 41% for placebo and 59% for active medication. Other studies done after 1990 confirmed these observations, but showed moderate to significant extrapyramidal symptom (EPS) side effects with haloperidol when the dose is 2-3 mg a day. For this reason, most clinicians recommend that elderly patients who require typical antipsychotic drugs receive doses approximately equal to 25-50% of the regular adult dosage.
Compared to older, conventional agents, the atypical antipsychotic drugs offer different side effects profiles including less EPS but potentially more orthostatic hypotension, cardiac arrhythmias and/or autonomic dysfunction. Metabolic derangement and propensity for diabetes can occur with longer term use of atypical antipsychotic medications. Among the atypicals the ones which have been most studied are risperidone and olanzapine [58] Risperidone has been shown to reduce psychosis and agitation with relatively few side effects at doses below 2 mg a day [117, 118]. Olanzapine has been shown to be effective in reducing agitation and psychosis with relatively low side effects with doses between 2 and 15 mg per day. Both risperidone and olanzapine can be given orally, utilizing rapid dissolving tablets that may be helpful in the elderly who are unable to swallow pills. In patients that require IM medication the alternatives for treatment are haloperidol, olanzapine, ziprazidone and aripiprazole. The recommended doses for geriatric patients, consistent with most elderly vs. younger populations, are 25-50% of the regular adult dosage.
Once the acute clinical state has been treated and resolved, the urgent treatment of the basic psychopathological state needs to be addressed. It is important to decide if the patient is suffering a bipolar disorder or a unipolar depression. This distinction is critical because if the patient is suffering a bipolar disorder the treatments of choice are "mood stabilizers" such as lithium carbonate or valproic acid, but if the patient is suffering a unipolar depression or an anxiety disorder the treatment of choice will generally be antidepressant medications.
While the treatment of depression in older patients often requires the use of medication treatment, effectiveness is increased if medication is combined with psychotherapy. According to meta-analysis done by Wilson and Mottram [119] the SSRIs and TCAs have comparable efficacy and tolerability. A similar statement can be made about the efficacy and tolerability of SNRIs. Selegiline, a selective MAO B inhibitor has been studied in older populations with Schneider and Sobin showing improvement in behavior, cognition and mood [120].
The main concern with these medications in the elderly is the potential for interactions with other medications and diet. The availability of a transdermal antidepressant patch may be useful in some patients with difficulties taking medications.
Psychotic depression occur in approximately 20-45% of hospitalized depressed elderly patients. Despite its relative frequency, that there is a lack of empirical data in the treatment of patients with depression accompanied by psychotic symptoms. The Expert Consensus Guidelines suggest the combination of an antidepressant and antipsychotic medication or electro convulsive therapy (ECT) as treatments for geriatric psychotic depression [121]. ECT has been found to be particularly effective in moderate to severe depression and depression with melancholic features, and in the case of psychotic depression, catatonia or treatment refractory conditions. Bipolar Disorders
The literature about the pharmacological treatment of older patients suffering a bipolar disorder is limited. Nemeroff [122] showed in patients 21 to 71 years old that a combination of paroxetine and lithium was more efficacious than lithium alone. Robillard [123] reported that lamotrigine was useful in addition to lithium or divalproex, and also useful in the maintenance of geriatric patients with bipolar disorder. Other alternatives are the use of the combination fluoxetine/olanzapine, the antipsychotic quetiapine or ECT in patients with manic episodes. In terms of the dosing of lithium, some clinicians suggest the utilization of the same lithium blood levels utilized in mixed aged adults, but there are reports of toxic reactions with this strategy motivating others to utilize lower blood levels (between 0.5 and 0.8 mEq/L). It is important to keep in mind drug-drug interaction and comorbid conditions in bipolar elders. Sajatovic and colleagues [124] have reported that older adults with bipolar disorder discharged from a geropsychiatric unit had a mean 3.7 medical illnesses — a ready setting for drug to drug interactions. There is good evidence that the use of divalproex in the treatment of mania and mixed episodes is efficacious and well tolerated but the studies involving older patients are limited [125]. While medications such as aripiprazole, olanzapine and quetiapine have been approved by the FDA for the treatment of manic episodes in mixed-age populations, there is little data regarding the efficacy of antipsychotic medication in the treatment of geriatric bipolar disorders.
Schizophrenia
When psychotic patients present with agitation due to an exacerbation of symptoms the treatment of choice must be directed to the management of the agitation in a safe and rapid way. The first step is to ensure that the patient and the people around are safe from physical danger. Patients in these conditions should be approached in a non-threatening matter with a show of force provided by trained personal. Sedation with intra-muscular (IM medication) and seclusion and/or physical restraints under careful supervision may be necessary to guarantee a proper treatment and evaluation.
Antipsychotic medications are the most effective symptomatic treatment for both early-onset and late-onset schizophrenic disorders. Because of age- related bodily changes that may affect the pharmacokinetics and pharmacodynamics of these medications in the elderly it is important to follow the principle of "start low and go slow" when using them.
The decision of which antipsychotic to use is very much predicated on the side effect profile of the particular medication in question. Significant improvement of psychotic symptoms has been reported with the typical antipsychotics haloperidol, trifluoperazine and thioridazine [126]. Typical antipsychotics have a wide variety of side effects related to their high affinity for the dopamine receptors. They also have anticholinergic and adrenergic side effects. For example, thioridazine produces the longest prolongation of the QT interval making this medication generally unsuitable for use in the elderly population.
Atypical antipsychotics have become the standard of care for their effectiveness with positive and negative symptoms and their relative lack of dopamine- related side effects (parkinsonian syndrome, akathisia, dystonias and tardive dyskinesia) but they are not free of side effects. Besides causing sedation and hypotension they may also produce prolongation of the QT interval as well as weight gain and serious metabolic side effects including causing or worsening diabetes [126]. Other medications commonly utilized in these cases are the short- acting benzodiazepines with lorazepam being the most utilized. Once the episode of agitation is controlled most patients are placed on regular, oral antipsychotic medication.
Patients with adherence problems must be considerd to be candidates for long acting medications such as haloperidol decanoate and long-acting, injectable risperidone. Howard and Levy [127] reported good outcomes, good adherence, and a reduced amount of medication with long acting- neuroleptics in older patients with psychosis.
Anxiety Disorders
Naturalistic studies looking at patients treated in primary care clinics for anxiety disorders point toward the use of anxiolytic or antidepressant medications in older patients but there is a lack of systematized studies. Despite side effects and problems with cognition and falls, benzodiazepines remain the mainstay of pharmacological therapy for acute management of anxiety and panic disorders and as an initial adjunct to therapy with SSRIs or SNRIs. These medications are beneficial because they have a rapid onset and little effect on the cardiovascular system. On the other hand the long term use has potential problems such as excessive daytime drowsiness, cognitive impairment, and confusion, increase risk for falls, respiratory problems and dependence potential with withdrawal syndromes. Because of the withdrawal syndromes it is recommended that older patients taking benzodiazepines for 4-6 weeks be tapered off them for at least 2-4 weeks.
For the older patient the recommended benzodiazepines are the ones with short half-life such as lorazepam, oxazepam and temazepam as they are inactivated by direct conjugation in the liver which is a mechanism minimally affected by normal aging.
Several studies have shown the efficacy of antidepressants in the treatment of anxiety disorders in the elderly. Sheik [128] found that imipramine and alprazolam were better than placebo in the treatment of anxiety. In another study the same authors showed that sertraline had a significant effect in the symptoms of anxiety. In one of the few prospective, randomized trails, Lenze and colleagues, demonstrated that citalopram was better than placebo in the treatment of generalized anxiety (GAD) (65% -vs- 27%) [129].
In a secondary analysis evaluating individuals age 60 and older, from several multicenter studies, Katz and colleagues [130] found a significant positive effect by venlafaxine in the treatment of symptoms of GAD. Azapirone and buspirone, as reported by Rickels and colleagues [131] have efficacy comparable to diazepam in patients with generalized anxiety disorder. Boehm and colleagues [132] reported that buspirone is well tolerated by geriatric patients and is effective for the remediation of chronic anxiety. Despite the results of some of these clinical studies the experience in "real world" clinical settings has not been satisfactory, creating the impression of inconsistence therapeutic results. Finally, other drugs utilized for the management of anxiety are antihistaminics such as hydroxyzine, beta blockers and antipsychotics but there are no good placebo controlled studies or the presence of side effects has precluded their use in the older patients.
Non-Pharma cologica l In terven tions
Elderly individuals suffering depressive, anxiety or bipolar disorders may benefit from psychotherapeutic interventions. A wide variety of therapies have been utilized with these patients but there is a scarcity of systematic, prospective studies. At present there is evidence showing that cognitive behavioral therapy and interpersonal therapy are probably the first line of non pharmacological intervention, and it is generally accepted that the utilization of psychotherapy plus medication is better that one of the two modalities alone. This has been studied for cognitive behavioral therapies [133]. Interpersonal therapy (IPT) has been studied and shown that is as effective as nortriptyline in older adults with fewer drop-outs [134]. Other therapies utilized but less studied are: Reminiscence Therapy, Brief Dynamic Therapy, Problem-Solving Therapy, Group therapy and Couple and Family therapy [135].
Future Outlook and Needed Research
Unfortunately, as is evident from the preceding text, treatment research on late-life aggressive behavior has lagged behind the pace of the growing population. Without appropriate management, aggressive behavior in the elderly has profound personal and societal consequence. For example, the older individual with dementia might be placed in a nursing home because his elderly spouse is unable to manage transient aggressive behavior. There is a critical need for greater understanding of biological and psychological underpinnings and precipitants of late-life aggression. Additionally expansion of evidence -based assessment protocols as well as treatments are essential. Treatments should ideally minimize both adverse effects on the individual as well as reduce burden to caregivers and families.
Three main types of interventions to manage aggression in older adult populations are currently being utilized. They are behavioral interventions, educational interventions and pharmacological interventions. All of these avenues both separately and in combination should be explored in order to refine and improve outcomes.
Final Commentary
Aggressive behavior in elderly populations is common and can be associated with acute medical conditions, toxic states, neurodegenerative conditions and acute or chronic psychiatric disorders. It is clear that population trends predict growing numbers of older adults and it is anticipated that there will be a great need for effective treatment approaches that minimize aggressive behavior and the effects of aggression in elders with a variety of medical, neurological and psychiatric disorders.
Current treatments appear to have efficacy in clinical trial settings, but have limited effectiveness in real-world, clinical settings. Public awareness of this growing problem, and large-scale exploration of treatment methods and technologies are essential in order to meet future healthcare needs of this population.
