Transcript
ReachMD Announcer:
Welcome to ReachMD. This medical industry feature, titled “Recognizing Agitation in Alzheimer’s Dementia: The AASC™- A Screening Tool for Caregivers,” is sponsored by Otsuka. Here’s your host, Dr. Charles Turck.
Dr. Turck:
This is ReachMD, and I’m Dr. Charles Turck. Today, our expert panel will discuss agitation associated with Alzheimer’s dementia, or AAD for short, and introduce a new screening tool for caregivers.
And making up our expert panel are Drs. Carolyn Clevenger and George Grossberg. Dr. Clevenger is a Professor at Emory University’s School of Nursing, as well as the Founder and Director of Integrated Memory Care in Atlanta, Georgia. Dr. Clevenger, welcome to the program.
Dr. Clevenger:
Thank you for having us.
Dr. Turck:
And Dr. Grossberg is the Inaugural Henry and Amelia Nasrallah Endowed Professor as well as Director of the Division of Geriatric Psychiatry in the Department of Psychiatry and Behavioral Neurosciences at St Louis University School of Medicine. Dr. Grossberg, thank you for being here today.
Dr. Grossberg:
It’s a pleasure to be here with you both.
Dr. Turck:
Dr. Clevenger, can you describe the current landscape of caregiving for individuals with Alzheimer's?
Dr. Clevenger:
Certainly. So Alzheimer’s dementia affects around 6.7 million adults aged 65 and older in the U.S in 2023 alone and is projected to almost double to 12.7 million by 2050.1
About 65 percent of those with Alzheimer’s live in community settings, receiving care from family members or other unpaid caregivers as their disease progresses.1
And so as the prevalence of Alzheimer’s increases, it’s essential to recognize the significant effect on individuals and their families as they navigate the challenges associated with Alzheimer’s.
Now as we know, the spectrum of symptoms in Alzheimer’s isn’t just confined to cognitive decline or functional impairment; it also includes a range of neuropsychiatric symptoms, such as agitation.1-4
Agitation is one of the most common neuropsychiatric symptoms for patients with Alzheimer’s dementia and manifests as both non-aggressive and aggressive behaviors.5-7 And these behavioral symptoms can significantly affect both patients and their caregivers.
Dr. Turck:
Dr. Grossberg, how exactly does AAD affect patients and caregivers?
Dr. Grossberg:
Well unfortunately, we’re seeing that AAD is highly prevalent across care settings and all stages and severities of Alzheimer’s dementia.5,8
The impact of agitation in Alzheimer’s dementia is multifaceted.8,9 For example, it’s been associated with outcomes such as accelerated disease progression, functional decline, earlier admission to long-term care facilities, and even earlier death.5,8-14 And if it occurs in the long-term care setting, AAD can be a trigger for falls, fractures, infections, hospitalizations, and emergency room visits — dramatically increasing healthcare expenditure.8,9,15
AAD also takes its toll on caregivers, whether they’re family members or professionals, such as in the long-term care environment. Among family caregivers, they may experience social isolation, feel embarrassment or guilt, have a reduced quality of life, or even increase their risk for depression and/or anxiety symptoms.4,16-21 And among professional caregivers, it’s a significant source of stress, burnout, higher turnover rates in settings that provide care for these individuals.8,22
So given this high burden on both patients and caregivers, we need to be able to recognize AAD early. And as we know, the current treatment paradigm includes developing a comprehensive, person-centered treatment plan that begins with nonpharmacological interventions to manage agitation symptoms. If these are unsuccessful, then judicious pharmacological intervention is recommended.23,24
And although clinicians may prescribe from various classes of medications to address agitation symptoms, there’s currently only one FDA-approved drug for the treatment of AAD.24-28
Dr. Turck:
Dr. Clevenger, how does AAD affect overall patient management given this high burden?
Dr. Clevenger:
Unfortunately, although nearly half of people living with Alzheimer’s dementia will experience agitation, clinicians and caregivers are often reluctant to discuss agitation symptoms.5,29,30
Caregivers may not recognize the full breadth of agitation behaviors, or they may not understand that there’s treatment for agitation separate from Alzheimer’s treatment.6,31,32 On the other hand, we as healthcare providers generally don’t always educate families about AAD until it becomes too challenging for caregivers.23,29,30
So there’s a need for early detection tools for caregivers, who are often the first to encounter agitation behaviors,30,33 because these tools may improve recognition and management of AAD by encouraging discussions with healthcare providers about symptoms.34
Dr. Turck:
Dr. Grossberg, what are current approaches to assessing or recognizing AAD?
Dr. Grossberg:
Well, as Dr. Clevenger just mentioned, because caregivers are often the first to experience and try to manage agitation behaviors, they play a critical role in recognizing, assessing, and communicating agitation symptoms to clinicians.1,23,30,31
And despite being one of the most common neuropsychiatric symptoms in Alzheimer’s dementia, agitated behaviors often go unrecognized.35
Now, we do have rating scales that measure agitation. These assessments include the Cohen-Mansfield Agitation Inventory, or the CMAI, the Pittsburgh Agitation Scale, or the PAS, and the Agitation/Aggression Subscale of the Neuropsychiatric Inventory, or NPI.36-39
But these tools are lengthy, they take quite a bit of time to complete, and aren’t widely used in clinical practice because they’re not user-friendly.6,7,31,36-40
So, there’s an unmet need for a simple screening tool that helps caregivers better understand AAD symptoms and empowers them to discuss AAD with clinicians. A practical screener tailored for AAD can not only help reassure caregivers, but may also improve patient outcomes and reduce caregiver burden.6,41,42
Dr. Turck:
Let’s turn our attention to a new screening tool for AAD. Dr. Grossberg, what was the rationale for its development, and how does it address some of the challenges posed by existing tools?
Dr. Grossberg:
So we developed the Agitation in Alzheimer’s Screener for Caregivers, or the AASC™ for short, to support caregivers in early recognition, facilitate discussions with clinicians, and aid in the potential diagnosis of AAD. We wanted this tool to be simple for caregivers to use by including behaviors that are easy to report. We also wanted this tool to take under one minute to complete and use straightforward scoring.34
In essence, we wanted to identify clinically meaningful agitation as defined by the four International Psychogeriatric Association, or IPA, criteria for agitation in cognitive disorders. These criteria not only highlight different types of agitated behaviors, such as excessive motor activity, verbal aggression, and physical aggression, but also require that these agitated behaviors represent a change from previous behaviors and are impactful on the quality of life of the patient and/or caregivers.6,34
Dr. Turck:
So now that we have some insights on the AASC, Dr. Clevenger, can you talk about the development process of this screening tool?
Dr. Clevenger:
I’d be happy to.
The AASC™ was co-created with family caregivers to make sure it was easy to understand as this is a caregiver-facing tool. The multi-stage process included a review of current literature and existing AAD assessment measures, and as Dr. Grossberg mentioned a bit earlier, the development was guided by the IPA definition of agitation in cognitive disorders. After we incorporated feedback from the clinical and patient advocacy experts for clinical completeness, it was further refined through scientifically structured interviews designed to validate the tool with family caregivers. These caregivers described the AASC™ as easy to understand and complete, as well as easy to share and start a discussion with a clinician.34
Dr. Turck:
Dr. Grossberg, can you walk us through the AASC™ screening tool?
Dr. Grossberg:
Sure. The AASC™ is composed of two main items designed to take less than one minute for a caregiver to complete at home or a clinic.34
In part one of the AASC™, caregivers answer yes or no to seven items which screen for AAD-related behavior changes.34
These include repeating motions or behaviors, pacing or restlessness, cursing or verbal outbursts, raising voice or yelling, resistance to assistance or care, and potentially harmful actions towards oneself or others.34
And the second part of the tool is a single yes or no question to screen for AAD-related effects on relationships, activities, or willingness to receive care.34
Any yes for question one, plus a yes on question two, is a positive screen. So, a yes on question one but a no on question two would not meet criteria as clinically meaningful agitation as the behaviors are not impactful to the relationships, activities, willingness to receive care, or quality of life.34
Dr. Turck:
Dr. Clevenger, what key takeaways would you like to leave with healthcare professionals who treat patients with Alzheimer’s dementia?
Dr. Clevenger:
So I think it’s important to keep in mind that agitation is highly prevalent, present in all stages and severities of Alzheimer’s dementia, and is associated with substantial patient and caregiver burden and long-term consequences.5,8 But despite being among the most common symptoms of Alzheimer’s dementia, agitation behaviors are largely unrecognized.35,42 Unfortunately, clinicians and caregivers don’t usually discuss symptoms of AAD until they become untenable for the caregiver.23,29,30 And so with all this in mind, we’ve developed a new screening tool for AAD in order to facilitate early detection of agitation behaviors by caregivers as well as improve the overall management of agitation in patients with Alzheimer’s dementia.34
Dr. Turck:
Dr. Grossberg, I’ll give you the final word.
Dr. Grossberg:
What I would emphasize is that, as Dr. Clevenger mentioned, agitation in Alzheimer’s dementia is a very common and disabling behavioral symptom.1,5,8,9 Second, it’s important for caregivers to always report behavior changes to their clinician.29-31 And finally, the good news is that we now have a brief, simple, user-friendly screening tool to identify clinically meaningful agitated behaviors in Alzheimer’s dementia for care partners to use and share the results with their clinician.34
Dr. Turck:
Thank you both, these are great concluding thoughts from our discussion.
Dr. Clevenger, Dr. Grossberg, it was wonderful speaking with you both today.
ReachMD Announcer:
This medical industry feature was sponsored by Otsuka. If you missed any part of this discussion, visit Industry Features on ReachMD.com, where you can Be Part of the Knowledge.
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