From the Guidelines
The best approach to manage agitation in an Alzheimer's disease patient involves first identifying and addressing potential triggers through non-pharmacological interventions before considering medications. This approach is supported by the American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia 1. Start by creating a calm environment with consistent routines, familiar objects, and appropriate lighting and sound levels, as suggested by guidelines for managing Alzheimer's disease 1. Ensure basic needs are met by checking for pain, hunger, thirst, or need for toileting. Simplify communication using short, clear sentences and a gentle tone. Provide meaningful activities that match the patient's abilities and interests.
Some key non-pharmacological interventions include:
- Providing a predictable routine for exercise, meals, and bedtime 1
- Allowing the patient to dress in their own clothing and keep possessions 1
- Explaining procedures and activities in simple language before performing them 1
- Simplifying tasks and providing instructions for each step 1
- Using distraction and redirection of activities to divert the patient from problematic situations 1
- Ensuring that comorbid conditions are optimally treated 1
- Providing a safe environment, including removing sharp-edged furniture, slippery floors, and obtrusive electric cords, and installing grab bars and safety locks 1
If non-pharmacological approaches are insufficient, medications may be considered, starting with the lowest effective dose. Options include low-dose atypical antipsychotics like risperidone (0.25-1mg daily), quetiapine (25-200mg daily), or olanzapine (2.5-10mg daily) for short-term use, as recommended by guidelines for managing Alzheimer's disease 1. SSRIs such as citalopram (10-20mg daily) or sertraline (25-100mg daily) may help with depression-related agitation. For severe agitation, short-term use of lorazepam (0.5-1mg) might be necessary. However, it's essential to regularly reassess and discontinue these medications when possible due to the risks of increased mortality, falls, and sedation 1. The underlying cause of agitation often stems from the patient's inability to communicate needs or from environmental overstimulation due to progressive neurodegeneration affecting brain regions that regulate emotion and behavior.
From the Research
Management of Agitation in Alzheimer's Disease
To manage agitation in Alzheimer's disease patients, a combination of non-pharmacological and pharmacological approaches can be used.
- Non-pharmacological interventions are suggested as first-line treatment 2
- Identifying and addressing medical and environmental precipitants remain a priority 3
- Psychosocial interventions and nonpharmacological approaches to care should ordinarily be the first option 4
Pharmacological Interventions
Pharmacological interventions can be used when non-pharmacological interventions are not effective.
- Acetylcholinesterase inhibitors and memantine can be initiated to enhance cognition 3
- Citalopram can be used to treat agitation, but attention should be paid to potential prolongation of the QT interval 3
- Low doses of atypical antipsychotics such as risperidone or quetiapine can be effective, but consideration of potential adverse effects is necessary 3, 5
- Other agents such as carbamazepine and selective serotonin reuptake inhibitors may also be used, but evidence is limited 4
Treatment Options
Several treatment options are available for agitation in Alzheimer's disease, including:
- Dextromethorphan/quinidine, scyllo-inositol, brexpiprazole, prazosin, cannabinoids, citalopram, escitalopram, pimavanserin, ITI-007, and ORM-12741, which show promise in treating agitation 2
- Olanzapine, quetiapine, and risperidone, which have been studied in clinical trials, but adverse effects may offset advantages in efficacy 5
- Trazodone, which can be used to manage insomnia or sundowning 3