Defining agitation in the cognitively impaired-a work in progress.

The International Psychogeriatric Association (IPA) being the leading international organization in the promotion of mental health and effective treatment of mental disorders in the elderly, has a long standing enviable tradition and track record in providing leadership in this field. In the 1990s,when it noted that the expressed behaviors of persons with dementia were generally referred to as “behavioral problems” whereby the persons with dementia were implicated as “problems” by this pejorative labeling, a concerted effort was mounted over some years to develop and promulgate the more appropriate clinical and non-judgemental term and related descriptions of Behavioral and Psychological Symptoms of Dementia (BPSD), removing the blame from the person and placed the “problem” on dementia pathology. Such a cultural change, with the support of a bio-psycho-social evidence based approach, has effected, in many places, a new and improved understanding leading to an improved quality of care for persons with dementia. Within the repertoire of BPSD, Agitation revealed itself as another target to be examined by IPA. The basic but perplexing question is “what is agitation?” when clinicians are confronted with some behaviors exhibited by persons with dementia. Reisberg (1987) developed the BEHAVEAD providing a rating scale which included behaviors which could be part of “agitation”. This was followed by the Cohen-Mansfield Agitation Inventory (Cohen-Mansfield et al., 1989) and the Cummings Neuropsychiatric Inventory (Cummings et al., 1994). These well validated measures of clinical symptoms have served us well in clinical and pharmacological research. Despite this, many clinicians and researchers are still unsure of the DEFINITION of “Agitation” as applied to persons with dementia and cognitive impairment. Is it the same as aggression as implied in these rating scales or are these separate or overlapping? The “lumping” of aggression with agitation, in the clinical environment, would have the same pejorative implication for the person with dementia as being labelled a “behavioral problem”. It confuses and confounds clarity in understanding and in management. To continue the work of IPA in the BPSD arena, the seeking, through the Agitation Definition Working Group (ADWG) of a real, practical, meaningful and useful consensus within the IPA membership and affiliates of clinicians and researchers in the field is a most worthy endeavor. It is hoped that this will bring about much needed clarity to again create a cultural change beneficial to the persons with dementia and cognitive impairment. The formation of the ADWG led by Professor Jeffery Cummings has, after much hard work, produced its first Report which proposed a Provisional Consensus definition. This important work now move the subject and its discussion forward towards the next important step of reaching a final Consensus definition which will enable the establishment of a practical, useful, clinically relevant definition which can support vigorous future evidence based research (Cummings et al., 1994). As with all development of Consensus statements, much challenge remained to be resolved. There are issues identified by this report requiring further exploration. There are some 14% (Table 5) of respondents who do not agree with the provisional definition. The vexed question of the difference between agitation and aggression remained unresolved, as two third (66%) of respondents consider them to be “overlapping concepts” while a third (32%) consider them to be “distinct”. The question whether verbal aggression and physical aggression as part and parcel of agitation be included in the definition remains unanswered. In this context, it is of interest to examine how the “consumers” (caregivers of PWD) view agitation and aggression. In the website of the Alzheimer’s Association (US) (http://www.alz.org/ care/alzheimers-dementia-agitation-anxiety.asp; http://www.alz.org/care/alzheimers-dementiaaggression-anger.asp) the two concepts are listed separately and the descriptions of the associated behaviors do not overlap. Similarly, the Alzheimer Australia website (http://www.fightdementia.org.