Neuropsychiatric symptoms in patients with dementia in Norwegian nursing homes : the course of the symptoms and the effect of discontinuation of psychotropic medication

Neuropsychiatric symptoms (NPS) are prevalent in dementia, and it has been estimated that up to 90% of people with dementia will experience NPS in the course of their dementia. Sometimes NPS in dementia are poorly diagnosed, and the effect of the treatment prescribed for the NPS has been poorly documented. The aim of this thesis was to describe the prevalence, course and treatment of NPS in Norwegian nursing homes. We wanted to study whether NPS are transient or persistent. In addition, we wanted to investigate the effect of discontinuing treatment with antidepressants and antipsychotics on patients in Norwegian nursing homes with dementia and NPS. We conducted a small pilot discontinuation study, and a large double blind randomised controlled discontinuation trial (DB RCT). Previous DB RCT discontinuation studies of antipsychotics have shown that discontinuation of the medication has been beneficial for the patients, while the effect of the discontinuation of antidepressants in patients with dementia and NPS has not previously been studied in a DB RCT. To obtain good assessments of the cognitive function of the patients in the study, most of them having moderate or severe dementia, we translated the Severe Impairment Battery (SIB) into Norwegian and validated this instrument. Four studies were conducted. In the validation study of the SIB 59 patients from three nursing homes in Hedmark and Oppland were included. In the study on the prevalence and the course of NPS in nursing homes, 210 patients from seven nursing homes in Hedmark and Oppland were included. In the pilot discontinuation study, 23 patients from seven nursing homes in Hedmark and Oppland were included, while in the DB RCT discontinuation study of antidepressants 128 patients from 52 nursing homes in 14 counties of Norway were included. The Severe Impairment Battery (SIB) is a cognitive test for patients with moderate to severe dementia (minimum score 0 and maximum score 100). In the SIB validation study, three psychiatrists/doctors drafted the cognitive questionnaire into Norwegian before a psychiatrist made a final Norwegian translation from the three drafts. A colleague born in Newcastle, who has lived in Norway for several decades, translated the Norwegian version of the SIB back into English, and this version corresponded well with the original English version. The patients' cognition and degree of dementia were examined with the SIB and the Clinical Dementia Rating scale (CDR), while the patients were diagnosed with dementia according to the International Classification of Diseases (ICD-10). A nurse and a doctor used the SIB to assess the patients within seven days of each other. The average SIB score was 72.10 points. In the reliability study Cronbach's alpha was 0.97, indicating a good internal reliability of the test. Spearman's rho correlation coefficient between the two testers was 0.85 for the total SIB score, and ranged between 0.46 and 0.76 for the sub-items of the test, which indicated a good inter-rater reliability. Scoring results on the SIB were compared with the CDR scores of patients. Spearman's rho correlation coefficient between the SIB score and the CDR score was 0.55. The groups of patients with CDR 1, 2 and 3 were significantly different from each other as measured by the SIB. By using Receiver Operating Characteristic (ROC) curve analysis we found that the SIB score of 87/88 best discriminated between CDR In the study of the prevalence and the course of NPS, patients were examined at baseline (T0) and after four (T1) eight (T2), twelve (T3) and sixteen (T4) months with the Neuropsychiatric Inventory (NPI), CDR, the Mini-Mental State Examination (MMSE) and the Quality of Life in late-stage dementia (QUALID) scale. The NPI examines NPS, and we reported the prevalence and course of the NPS identified with the NPI. At baseline, the average age of the patients included was 84.9 years, 69.2% were female and the median length of stay in the nursing home was 673 days. The three most prevalent NPS were irritability, agitation/aggression and apathy (T0 and T1), irritability, agitation/aggression and disinhibition (T2 and T3) and depression, disinhibition and irritability (T4). Irritability had the highest cumulative prevalence (63.5%), followed by agitation/aggression (51.0%) and disinhibition (50.0%). In total, 91.7% of patients had at least one NPS during the 16 months period. Irritability (42.6%), disinhibition (37.8%) and depression (31.5%) had the highest cumulative incidence. The most persistent NPS were agitation/aggression, irritability and disinhibition (T0-T1) and (T1-T2), disinhibition, apathy and irritability (T2-T3) and hallucinations, depression and anxiety (T3-T4). The NPS with highest resolution rate were euphoria, appetite and eating disorders, and sleep and night-time behaviour disorders (T0-T1) and (T1-T2), appetite and eating disorders, hallucinations and delusions (T2-T3) and appetite and eating disorders, euphoria and apathy (T3-T4). The conclusion of this study is that almost all patients included in this study have one or more NPS in the course of sixteen months, but individual symptoms fluctuate, which should affect the treatment which patients are given. In the small pilot study where we investigated the effect of the discontinuation of antidepressants and antipsychotics, 23 patients with dementia, but without a depressive disorder, were included. Twelve patients used antipsychotics of different types and 11 patients used selective serotonin reuptake inhibitor (SSRI) antidepressants. Patients were examined at baseline with the CDR, the NPI, the Cornell Scale for Depression in Dementia (CSDD), a sub-scale of the Unified Parkinson's Disease Rating Scale (UPDRS), the SIB, the Lawton and Brody's Physical Self-Maintenance Scale (PSMS) and the Quality of Life-Alzheimer's Disease (QoL-AD) scale. At three, six and 12 weeks, patients were examined with the NPI and the UPDRS, and after 24 weeks the same assessment scales as at baseline were used. At inclusion the average age was 84.1 years and 91.3% were women. At three and six weeks, we found a small increase in the NPI and the UPDRS scores of patients in both groups, but at 12 and 24 weeks the scores on both scales were back to baseline levels. The SIB scores (cognition) at 24 weeks showed a slight decrease in the group who discontinued antidepressant medication and a small increase in the group who discontinued antipsychotics. The CSDD scores were unchanged in the antipsychotic group, but showed a small decrease in the antidepressant group. None of the results were statistically significant, but suggested that discontinuation of antidepressants and antipsychotics were safe in the patients with dementia and NPS, and could even be beneficial for the patients. In the randomised double-blind RCT discontinuation study of antidepressants, the 128 patients were assessed with the same assessment tools as in the pilot study and the assessments were done at baseline and after four, seven, 13 and 25 weeks. The 128 patients used escitalopram, citalopram, sertraline or paroxetine at inclusion. In half of the patients the antidepressive medication was discontinued, while in the other half of the patients the medication was continued. The study was double blind and placebocontrolled, meaning that in patients who discontinued medication the antidepressant was substituted by placebo tablets or capsules identical in appearance to the study medication in those who continued with medication. Neither the patients, the relatives, employees at the nursing home or the study management knew which patients were in the discontinuation group and which were in the active medication group, as randomisation and distribution of the study medication was made by the hospital pharmacy at Innlandet Hospital Trust, Gjøvik. Randomisation was by a computer-generated 1:1 allocation sequence. Sixty-three patients were allocated to the antidepressants discontinuation group (ADG), out of which 27 patients (42.9%) had to discontinue the study within 25 weeks. Sixty-five patients were allocated to the antidepressants continuation group (ACG), out of which 18 patients (27.7%) had to discontinue the study within 25 weeks. At baseline, the groups were comparable in terms of age, gender, NPI score, CSDD score and all the other measured variables. At 25 weeks, the ADG group had an increase of 2.53 points on the CSDD from 5.03 points while the ACG group had a decrease of -0.43 point from 5.89 points. The difference between the groups was statistically significant. A post hoc analysis showed that the difference in the total CSDD score between the groups were statistically significant different as early as at week 7 (visit 3). Measured with the NPI the ADG group had an increase of 5.93 points from 17.79 points while the ACG group had a decrease of - 1.39 points from 17.63 points. When analysing the results with ANCOVA, and correcting for the baseline values of the CSDD, the difference between groups was still statistically significant. We analysed the mood sub-scores of the CSDD, based on a Norwegian factor analysis (Barca et al., 2008), and the affective subscales of the NPI (NPI-depression + NPI Anxiety) to examine the mood symptoms of the patients. This analysis also showed statistically significant differences between the groups. For the other assessment tools – the CDR, the UPDRS, the QoL-AD and the PSMS – there were no statistically significant changes between baseline and 25 weeks. We concluded that discontinuation of antidepressants in patients who have dementia and NPS, but no depressive disorder, led to an increase in depressive symptoms

Exploring the trajectories of quality of life and its covariates in nursing home residents: A longitudinal study

Background: There is no cure for dementia and appropriate care should be offered to improve or maintain quality of life for those living with dementia. Objectives: To identify groups of residents following similar trajectories of quality of life after nursing home admission, to examine which resident, staff, and organizational characteristics at baseline differ between the identified groups, and to assess the associations between the trend in quality of life and the same characteristics measured at baseline and over the study period. Design: A prospective, observational, longitudinal cohort design over 30 months. Setting: Nursing homes in Norway. Participants: Residents admitted to nursing homes. Measurements: Resident data on quality of life, dementia, pain, activities of daily living, physical health, neuropsychiatric symptoms, medication, and demographic characteristics were obtained by interviews. Unit characteristics and the staff data on person-centered care, psychosocial factors, and job satisfaction were obtained by questionnaires and interviews. The physical environment of the unit was assessed by structured observation. Results: 694 residents admitted to a nursing home and 1161 staff from 175 nursing home units participated. Three resident groups following similar trajectories in quality of life were identified by growth mixture model; good quality of life (53.6%), moderate quality of life (32.9%), and poor quality of life (13.4%). All groups’ quality of life decreased over time. More pain, more severe dementia, and more affective symptoms at baseline were associated with belonging to the poor quality of life group. Overall decline in quality of life was associated with more severe dementia, more pain, poorer function in activities of daily living, more severe neuropsychiatric symptoms among residents, and poorer job satisfaction among staff. Conclusion: Reducing pain, reducing NPS, improving activities of daily living for the residents, and improving the staff’s job satisfaction may be factors of importance to improve the residents’ quality of life.The REDIC-NH study was administrated by the Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, and was initiated by the Norwegian Health Directorate, which also provided funding for the data collection. The first author’s Ph. D. study was funded by the Research Council of Norway.publishedVersio

Trajectories of physical performance in nursing home residents with dementia

Background In nursing homes (NH) the prevalence of dementia ranges from 50 to 84% and most residents have extensive physical-performance impairments. However, from time of admission, development of physical performance in NH residents with dementia remains unexplored. Aims To explore the overall trend in physical performance, associated characteristics, and groups following distinct trajectories from time of admission, in NH residents with dementia. Methods We followed newly admitted NH residents diagnosed with dementia (N=583) from 47 NHs across Norway for 3 years. Individual assessments were conducted biannually, and main outcome measure was the Short Physical Performance Battery (SPPB). Facility-level characteristics included unit size, staf-to-resident ratio, and quality of the physical environment (Special Care Unit Environmental Quality Scale, SCUEQS). Results From time of admission, NH residents with dementia showed a signifcant overall decline in physical performance. Further, we identifed three distinct trajectory groups with signifcantly diferent baseline physical-performance status (“good,” “moderate,” and “poor”), diferences between groups maintained and all declined across time. Younger age, good general medical health, less-severe dementia, and less musculoskeletal pain were associated with both an average higher overall trend and better baseline group-belonging. Additionally, less apathy and more psychosis were associated with a higher overall trend, and agitation was associated with poorer baseline group-belonging. Conclusions To prevent excessive decline in physical performance in this population, NH clinicians should focus eforts specifcally on assessment of physical performance at admission and on identifcation and management of musculoskeletal pain and neuropsychiatric symptoms. Keywords Physical performance · Trajectories · Dementia · Nursing homepublishedVersio

Insomnia and risk of dementia in a large population-based study with 11-year follow-up: The HUNT study

Despite evidence suggesting that insomnia is associated with the risk of dementia and cognitive dysfunction, studies have shown mixed results. Dementia has a long prodromal phase, and studies with long follow-up are required to avoid reverse causality. In our 11-year follow-up study, we assessed whether probable insomnia disorder (PID) based on diagnostic criteria, and insomnia symptoms were associated with risk of all-cause dementia, Alzheimer's disease (AD) and cognition, measured with the Montreal Cognitive Assessment scale. We also examined if Apolipoprotein E genotype modified any associations with dementia through interaction. We analysed data from 7492 participants in the Norwegian Trøndelag Health Study. PID was not associated with all-cause dementia (odds ratio = 1.03, 95% confidence interval = 0.74-1.43), AD (odds ratio = 1.07, 95% confidence interval = 0.71-1.60) or Montreal Cognitive Assessment score (regression coefficient = 0.37, 95% confidence interval = -0.06 to 0.80). The insomnia symptom "difficulties maintaining sleep" was associated with a lower risk of all-cause dementia (odds ratio = 0.81, 95% confidence interval = 0.67-0.98), AD (odds ratio = 0.73, 95% confidence interval = 0.57-0.93), and better Montreal Cognitive Assessment score, mean 0.40 units (95% confidence interval = 0.15-0.64). No interaction with Apolipoprotein E genotype was found. PID and insomnia symptoms did not increase the risk of dementia in our study. More research with longer follow-up is needed, and future studies should explore if the associations to dementia risk vary across insomnia subtypes

Prevalence and Determinants of Diagnosed Dementia: A Registry Linkage Study Linking Diagnosis of Dementia in the Population-Based HUNT Study to Registry Diagnosis of Dementia in Primary Care and Hospitals in Norway

BACKGROUND: A timely diagnosis of dementia can be beneficial for providing good support, treatment, and care, but the diagnostic rate remains unknown and is probably low. OBJECTIVE: To determine the dementia diagnostic rate and to describe factors associated with diagnosed dementia. METHODS: This registry linkage study linked information on research-based study diagnoses of all-cause dementia and subtypes of dementias, Alzheimer's disease, and related dementias, in 1,525 participants from a cross-sectional population-based study (HUNT4 70+) to dementia registry diagnoses in both primary-care and hospital registries. Factors associated with dementia were analyzed with multiple logistic regression. RESULTS: Among those with research-based dementia study diagnoses in HUNT4 70+, 35.6% had a dementia registry diagnosis in the health registries. The diagnostic rate in registry diagnoses was 19.8% among home-dwellers and 66.0% among nursing home residents. Of those with a study diagnosis of Alzheimer's disease, 35.8% (95% confidence interval (CI) 32.6-39.0) had a registry diagnosis; for those with a study diagnosis of vascular dementia, the rate was 25.8% (95% CI 19.2-33.3) and for Lewy body dementias and frontotemporal dementia, the diagnosis rate was 63.0% (95% CI 48.7-75.7) and 60.0% (95% CI 43.3-75.1), respectively. Factors associated with having a registry diagnosis included dementia in the family, not being in the youngest or oldest age group, higher education, more severe cognitive decline, and greater need for help with activities of daily living. CONCLUSIONS: Undiagnosed dementia is common, as only one-third of those with dementia are diagnosed. Diagnoses appear to be made at a late stage of dementia

Exploring life-space in the nursing home. An observational longitudinal study

Background Traditional performance-based measurements of mobility fail to recognize the interaction between the individual and their environment. Life-space (LS) forms a central element in the broader context of mobility and has received growing attention in gerontology. Still, knowledge on LS in the nursing home (NH) remains sparse. The aim of this study was to identify LS trajectories in people with dementia from time of NH admission, and explore characteristics associated with LS over time. Methods In total, 583 people with dementia were included at NH admission and assessed biannually for 3 years. LS was assessed using the Nursing Home Life-Space Diameter. Association with individual (age, sex, general medical health, number of medications, pain, physical performance, dementia severity, and neuropsychiatric symptoms) and environmental (staff-to-resident ratio, unit size, and quality of the physical environment) characterises was assessed. We used a growth mixture model to identify LS trajectories and linear mixed model was used to explore characteristics associated with LS over time. Results We identified four groups of residents with distinct LS trajectories, labelled Group 1 (n = 19, 3.5%), Group 2 (n = 390, 72.1%), Group 3 (n = 56, 10.4%), Group 4 (n = 76, 14.0%). Being younger, having good compared to poor general medical health, less severe dementia, more agitation, less apathy, better physical performance and living in a smaller unit were associated with a wider LS throughout the study period. Conclusion From NH admission most NH residents’ LS trajectory remained stable (Group 2), and their daily lives unfolded within their unit. Better physical performance and less apathy emerged as potentially modifiable characteristics associated with wider LS over time. Future studies are encouraged to determine whether LS trajectories in NH residents are modifiable, and we suggest that future research further explore the impact of environmental characteristics.publishedVersio

Cognitive Trajectories in Older Patients with Cancer Undergoing Radiotherapy—A Prospective Observational Study

Cognitive function can be affected by cancer and/or its treatment, and older patients are at a particular risk. In a prospective observational study including patients 65 years referred for radiotherapy (RT), we aimed to investigate the association between patient- and cancer-related factors and cognitive function, as evaluated by the Montreal Cognitive Assessment (MoCA), and sought to identify groups with distinct MoCA trajectories. The MoCA was performed at baseline (T0), RT completion (T1), and 8 (T2) and 16 (T3) weeks later, with scores ranging between 0 and 30 and higher scores indicating better function. Linear regression and growth mixture models were estimated to assess associations and to identify groups with distinct MoCA trajectories, respectively. Among 298 patients with a mean age of 73.6 years (SD 6.3), the baseline mean MoCA score was 24.0 (SD 3.7). Compared to Norwegian norm data, 37.9% had cognitive impairment. Compromised cognition was independently associated with older age, lower education, and physical impairments. Four groups with distinct trajectories were identified: the very poor (6.4%), poor (8.1%), fair (37.9%), and good (47.7%) groups. The MoCA trajectories were mainly stable. We conclude that cognitive impairment was frequent but, for most patients, was not affected by RT. For older patients with cancer, and in particular for those with physical impairments, we recommend an assessment of cognitive function.This work was funded by Innlandet Hospital Trust, Norway. This research received no external funding.publishedVersio

Body mass index in nursing home residents during the first year after admission

La desnutrición, que comprende tanto la desnutrición como el sobrepeso, debe ser abordada en el seguimiento médico de los adultos mayores debido a las consecuencias negativas para el estado funcional y la salud general. Aún así, se sabe poco sobre el estado nutricional de los residentes de hogares de ancianos (NH), especialmente con respecto al aumento o la pérdida de peso después de la admisión a NH. Por lo tanto, este estudio tiene como objetivo evaluar los cambios en el índice de masa corporal (IMC) durante el primer año posterior al ingreso a NH y explorar las características demográficas y clínicas relacionadas con los cambios en el IMC. Métodos Se combinaron los datos de dos estudios prospectivos que reclutaron participantes al ingreso a NH. Las características demográficas y clínicas, incluido el IMC, se evaluaron al inicio y después de un año. Se estimó un modelo de regresión lineal para explorar el impacto de las características demográficas y clínicas en el cambio del IMC. Resultados La cohorte del estudio constaba de 1044 participantes con una edad media de 84,3 años (DE 7,6) al inicio del estudio; El 64,2% eran mujeres. Al inicio del estudio, el 33% de los residentes de NH tenían desnutrición severa a moderada, mientras que el 10% eran obesos. Durante el primer año de su estadía en NH, los residentes con desnutrición severa a moderada tuvieron un aumento promedio en el IMC de 1,3 kg/m2 (DE 2,2; p < 0,001), mientras que los cambios de peso fueron muy pequeños o no significativos en los otros grupos de IMC . Las características relacionadas con el aumento de peso fueron una edad más joven y menos agitación. Conclusión La desnutrición es un desafío de salud común al momento de la admisión a NH, con un tercio de los residentes de NH con un peso bajo moderado a severo y un 10% con obesidad. Sin embargo, durante el primer año de estancia en NH, hubo una evolución favorable para los residentes de NH con bajo peso, ya que aumentaron su IMC, y el 43,6% cambió a una clasificación de mayor peso, mientras que no observamos cambios en el IMC en los residentes con obesidad. Dado que los residentes de NH se encuentran en la última fase de sus vidas, las intervenciones para prevenir la desnutrición o el sobrepeso deben iniciarse mientras aún viven en el hogar y luego continuar en los hogares de ancianos.Q2Q2Malnutrition - comprising both undernutrition and overweight - has to be addressed in the medical follow-up of older adults due to the negative consequences for the functional state and general health. Still, little is known about the nutritional state of nursing home (NH) residents, especially with respect to weight gain or weight loss after NH admission. Therefore, this study aims to evaluate changes in the body mass index (BMI) during the first year following NH admission, and to explore demographic and clinical characteristics related to BMI changes. Methods Data from two prospective studies that recruited participants at NH admission were combined. Demographic and clinical characteristics including the BMI were assessed at baseline and after one year. A linear regression model was estimated to explore the impact of demographic and clinical characteristics on the change in BMI. Results The study cohort consisted of 1,044 participants with a mean age of 84.3 years (SD7.6) at baseline; 64.2% were female. At baseline, 33% of the NH residents had severe to moderate undernutrition, while 10% were obese. During the first year of their NH stay, residents with severe to moderate undernutrition had an average increase in BMI of 1.3 kg/m2 (SD 2.2; p < 0.001), while weight changes were either very small or not significant in the other BMI groups. Characteristics related to weight gain were younger age and less agitation. Conclusion Malnutrition is a common health challenge at NH admission, with one third of NH residents being moderately to severely underweight and 10% being obese. However, during the first year of NH stay, there was a favourable development for underweight NH residents, as they increased their BMI, and 43.6% changed to a higher weight classification, while we observed no changes in the BMI in residents with obesity. As NH residents are in the last phase of their lives, interventions to prevent malnutrition or overweight should be initiated while still home-dwelling, and then continued in the nursing homes.https://orcid.org/0000-0001-5832-0603https://scholar.google.com/citations?user=MrICwaMAAAAJ&hl=enhttps://scienti.minciencias.gov.co/cvlac/visualizador/generarCurriculoCv.do?cod_rh=0001429659Revista Internacional - IndexadaS

Temporal changes in personal activity intelligence and the risk of incident dementia and dementia related mortality: A prospective cohort study (HUNT)

Background: The Personal Activity Intelligence (PAI) translates heart rate during daily activity into a weekly score. Obtaining a weekly PAI score ≥100 is associated with reduced risk of premature morbidity and mortality from cardiovascular diseases. Here, we determined whether changes in PAI score are associated with changes in risk of incident dementia and dementia-related mortality. Methods: We conducted a prospective cohort study of 29,826 healthy individuals. Using data from the Trøndelag Health-Study (HUNT), PAI was estimated 10 years apart (HUNT1 1984-86 and HUNT2 1995-97). Adjusted hazard-ratios (aHR) and 95%-confidence intervals (CI) for incidence of and death from dementia were related to changes in PAI using Cox regression analyses. Findings: During a median follow-up time of 24.5 years (interquartile range [IQR]: 24.1-25.0) for dementia incidence and 23.6 years (IQR: 20.8-24.2) for dementia-related mortality, there were 1998 incident cases and 1033 dementia-related deaths. Individuals who increased their PAI score over time or maintained a high PAI score at both assessments had reduced risk of dementia incidence and dementia-related mortality. Compared with persistently inactive individuals (0 weekly PAI) at both time points, the aHRs for those with a PAI score ≥100 at both occasions were 0.75 (95% CI: 0.58-0.97) for incident dementia, and 0.62 (95% CI: 0.43-0.91) for dementia-related mortality. Using PAI score <100 at both assessments as the reference cohort, those who increased from <100 at HUNT1 to ≥100 at HUNT2 had aHR of 0.83 (95% CI: 0.72-0.96) for incident dementia, and gained 2.8 (95% CI: 1.3-4.2, P<0.0001) dementia-free years. For dementia-related mortality, the corresponding aHR was 0.74 (95% CI: 0.59-0.92) and years of life gained were 2.4 (95% CI: 1.0-3.8, P=0.001). Interpretation: Maintaining a high weekly PAI score and increases in PAI scores over time were associated with a reduced risk of incident dementia and dementia-related mortality. Our findings extend the scientific evidence regarding the protective role of PA for dementia prevention, and suggest that PAI may be a valuable tool in guiding research-based PA recommendations. Funding: The Norwegian Research Council, the Liaison Committee between the Central Norway Regional Health Authority and Norwegian University of Science and Technology (NTNU), Trondheim, Norway.The Norwegian Research Council, the Liaison Committee between the Central Norway Regional Health Authority and Norwegian University of Science and Technology (NTNU), Trondheim, Norway.publishedVersio

Reduction and prevention of agitation in persons with neurocognitive disorders: an international psychogeriatric association consensus algorithm

Objectives: To develop an agitation reduction and prevention algorithm is intended to guide implementation of the definition of agitation developed by the International Psychogeriatric Association (IPA). Design: Review of literature on treatment guidelines and recommended algorithms; algorithm development through reiterative integration of research information and expert opinion. Setting: IPA Agitation Workgroup. Participants: IPA panel of international experts on agitation. Intervention: Integration of available information into a comprehensive algorithm. Measurements: None. Results: The IPA Agitation Work Group recommends the Investigate, Plan, and Act (IPA) approach to agitation reduction and prevention. A thorough investigation of the behavior is followed by planning and acting with an emphasis on shared decision-making; the success of the plan is evaluated and adjusted as needed. The process is repeated until agitation is reduced to an acceptable level and prevention of recurrence is optimized. Psychosocial interventions are part of every plan and are continued throughout the process. Pharmacologic interventions are organized into panels of choices for nocturnal/circadian agitation; mild-moderate agitation or agitation with prominent mood features; moderate-severe agitation; and severe agitation with threatened harm to the patient or others. Therapeutic alternatives are presented for each panel. The occurrence of agitation in a variety of venues-home, nursing home, emergency department, hospice-and adjustments to the therapeutic approach are presented. Conclusions: The IPA definition of agitation is operationalized into an agitation management algorithm that emphasizes the integration of psychosocial and pharmacologic interventions, reiterative assessment of response to treatment, adjustment of therapeutic approaches to reflect the clinical situation, and shared decision-making.publishedVersio