What medication is preferred for managing agitation in elderly patients with dementia?

From the Guidelines

Selective serotonin reuptake inhibitors (SSRIs) are generally preferred as first-line treatment for managing agitation in elderly patients with dementia, due to their ability to reduce overall neuropsychiatric symptoms, agitation, and depression with a more favorable side effect profile compared to antipsychotics. When considering medication, it's essential to weigh the potential benefits against the risks, particularly the increased mortality associated with antipsychotic use in this population 1. Non-pharmacological approaches, such as simulated presence therapy, massage therapy, and personalized interventions, should be explored first, as they can be effective in reducing agitation without the risks associated with medication 1. If medication is necessary, SSRIs like sertraline or citalopram may be considered, given their efficacy and relatively favorable side effect profile 1. Atypical antipsychotics, such as quetiapine or risperidone, may be used as a last resort, but with careful monitoring and at the lowest effective dose for the shortest duration possible, due to the increased risk of mortality and other adverse effects 1.

Key considerations when managing agitation in elderly patients with dementia include:

• Identifying and addressing underlying causes of agitation, such as pain, infection, or environmental factors
• Regular monitoring for side effects, including sedation, falls, and metabolic changes
• Involving patients and caregivers in shared decision-making, with clear discussion of potential risks and benefits
• Prioritizing non-pharmacological approaches and reserving medication for cases where these interventions are insufficient.

From the Research

Medication Preferences for Managing Agitation in Elderly Patients with Dementia

• The preferred medication for managing agitation in elderly patients with dementia is not universally agreed upon, but several options are considered based on patient comorbidities, specific symptoms, and tolerance to medications 2.
• Selective serotonin reuptake inhibitors (SSRIs), such as citalopram and sertraline, have been associated with a reduction in symptoms of agitation when compared to placebo in some studies 3, 4, 5.
• Citalopram, in particular, has been found to be effective in treating agitation in Alzheimer's disease dementia, although its use is limited due to concerns about cardiac side effects 5.
• Atypical antipsychotics, such as risperidone and quetiapine, can also be effective in treating agitation, but their use requires careful consideration of potential adverse effects 4.
• Trazodone may be used to manage insomnia or sundowning in patients with dementia, and it has been found to be reasonably well-tolerated when compared to placebo, typical antipsychotics, and atypical antipsychotics 3, 4.
• Acetylcholinesterase inhibitors and memantine may be initiated to enhance cognition, and they may also have a positive effect on agitation symptoms 4.

Key Considerations

• The choice of medication depends on the individual patient's needs and circumstances, and a "one-size fits all" approach is not appropriate for managing agitation in dementia 4.
• Non-pharmacological management should be exhausted before initiating pharmacological treatment, and the patient's medical and environmental precipitants should be identified and addressed 2, 4, 6.
• Future research is needed to determine the safety and efficacy of various medications for treating agitation in dementia, and to develop more effective treatment strategies for this common and challenging symptom 2, 3, 6, 5.