What is the suggested medication management for dementia patients with behavioral disturbances, agitation, and sundowning?

From the Guidelines

Medication management for dementia patients with behavioral disturbances, agitation, and sundowning should prioritize non-pharmacological approaches, with medications used cautiously as second-line interventions, as recommended by the American Psychiatric Association practice guideline 1.

Key Considerations

• Non-pharmacological interventions, such as providing a predictable routine, simplifying tasks, and ensuring a safe environment, should be the first line of treatment for behavioral disturbances in dementia patients 1.
• When medications are necessary, atypical antipsychotics like risperidone, quetiapine, or olanzapine may be prescribed at the lowest effective dose for the shortest duration possible, due to their potential benefits in reducing agitation, despite carrying black box warnings for increased mortality in elderly patients with dementia 1.
• For sundowning specifically, a small dose of melatonin in the evening may help regulate sleep-wake cycles, while trazodone can be useful for sleep disturbances, and SSRIs like citalopram may help with depression and anxiety components of agitation.

Medication Options

• Atypical antipsychotics: risperidone (0.25-1mg daily), quetiapine (25-200mg daily), or olanzapine (2.5-10mg daily) 1.
• Melatonin: 1-3mg in the evening for sundowning.
• Trazodone: 25-100mg for sleep disturbances.
• SSRIs: citalopram (10-20mg daily) for depression and anxiety components of agitation.

Monitoring and Safety

• Regular monitoring for side effects, including extrapyramidal symptoms, sedation, falls, and metabolic changes, is essential when using medications to manage behavioral disturbances in dementia patients.
• Medication trials should be time-limited with regular attempts to taper or discontinue, as the risk-benefit ratio changes over time and with disease progression 1.

From the Research

Medication Management for Dementia with Behavioral Disturbances

• The management of agitation in dementia patients is a complex issue, and various pharmacological interventions have been studied to address this problem 2, 3, 4, 5.
• Selective serotonin reuptake inhibitors (SSRIs) such as citalopram have been associated with a reduction in symptoms of agitation and lower risk of adverse effects compared to antipsychotics 2, 3, 4.
• Citalopram and escitalopram have been found to be effective in treating agitation in Alzheimer's disease dementia, with citalopram being associated with a reduction in symptoms of agitation and lower risk of adverse effects 3.
• However, concerns about the cardiac side-effects of citalopram have limited its widespread use for this indication 3.
• Antidepressants such as SSRIs and trazodone have been found to be tolerated reasonably well when compared to placebo, typical antipsychotics, and atypical antipsychotics 4.
• Acetylcholinesterase inhibitors and memantine should be initiated to enhance cognition, and if present, management of insomnia or sundowning with trazodone is indicated 5.
• Treatment with low doses of atypical antipsychotics such as risperidone or quetiapine can be effective after appropriate consideration of and disclosure of potential adverse effects 5.

Treatment Options for Agitation in Dementia

• Identifying and addressing medical and environmental precipitants remain a priority in the management of agitation in dementia patients 5.
• If agitation persists, treatment with citalopram can be initiated with attention paid to potential prolongation of the QT interval 5.
• Many options exist that can be prudently pursued for the management of agitation in dementia, and there is no "one-size fits all" approach to agitation in Alzheimer's disease 5.
• The use of SSRIs and serotonin and noradrenaline reuptake inhibitors (SNRIs) has been found to be differentially associated with the risk of dementia in patients with depression 6.