What are the medications for agitation in Parkinson's disease (PD) dementia?

From the Guidelines

Medications for Agitation in Parkinson's Disease (PD) Dementia Agitation in Parkinson's disease dementia should be managed with non-pharmacological interventions as the first line of treatment. However, if medications are necessary, consider using low-dose atypical antipsychotics such as quetiapine (12.5-25mg at bedtime) or olanzapine (2.5-5mg at bedtime) with close monitoring due to potential side effects 1.

• Atypical antipsychotics:
  • Quetiapine: initial dosage 12.5mg twice daily, maximum 200mg twice daily 1
  • Olanzapine: initial dosage 2.5mg at bedtime, maximum 10mg at bedtime 1
• Mood-stabilizing (antiagitation) drugs:
  • Trazodone: initial dosage 25mg per day, maximum 200-400mg per day in divided doses 1
  • Divalproex sodium: initial dosage 125mg twice daily, titrate to therapeutic blood level (40-90 mcg per mL) 1
• Cholinesterase inhibitors:
  • Rivastigmine: initial dosage 1.5mg twice daily, maximum 6mg twice daily 1

It's essential to start with low doses and gradually increase as needed and tolerated, under close supervision. The goal is to use the minimum effective dose for the shortest duration necessary to manage symptoms. Regular assessment and monitoring of the patient's condition and potential side effects are crucial 1.

Important considerations:

• Always review the clinical response to non-pharmacological interventions prior to nonemergency use of an antipsychotic medication to treat agitation or psychosis in patients with dementia 1
• Deprescribing of cholinesterase inhibitors or memantine should occur gradually and treatment reinitiated if the individual shows clinically meaningful worsening of cognition, functioning, neuropsychiatric symptoms, or global assessment that appears to be related to cessation of therapy 1

From the Research

Medications for Agitation in Parkinson's Disease (PD) Dementia

There is limited information available on medications specifically for agitation in PD dementia. However, the following points can be noted:

• Anti-depressants, anti-psychotics, or anti-epileptics in conjunction with cholinesterase inhibitors may be used to manage behavioral and psychological symptoms of dementia (BPSD), including agitation, depending on patient comorbidities and specific BPSD presentation 2.
• Neuroleptics and other psychoactive drugs may be used to treat delirium in PD patients with severe agitation or distressing psychosis, but their administration is controversially discussed 3.
• Adjustments of anti-parkinsonian medication may be recommended to prevent or treat delirium, but no hard evidence is available from controlled studies 3.

Non-Pharmacological Interventions for Agitation in Dementia

Non-pharmacological interventions may be effective in reducing agitation in dementia patients, including those with PD dementia. Some of these interventions include:

• Person-centred care, communication skills training, and adapted dementia care mapping, which have been shown to decrease symptomatic and severe agitation in care home residents 4, 5.
• Activities and music therapy by protocol, which have been found to reduce overall agitation and sensory intervention, which can decrease mean and clinically significant symptoms 4, 5.
• Massage therapy, animal-assisted intervention, and personally tailored intervention, which have been associated with more substantial reductions in agitation compared to other interventions and controls 6.