From the Guidelines
The first line treatment for agitation in patients with dementia is selective serotonin reuptake inhibitors (SSRIs), as they have been shown to significantly reduce overall neuropsychiatric symptoms, agitation, and depression in individuals with vascular cognitive impairment (VCI) or dementia. According to the Canadian Stroke Best Practice Recommendations: Vascular Cognitive Impairment, 7th Edition practice guidelines update, 2024 1, SSRIs are considered first-line treatments for agitation in patients with dementia. This is because they have been found to improve symptoms of agitation and depression, while also reducing the risk of adverse effects associated with other medications such as typical and atypical antipsychotics.
Some key points to consider when treating agitation in patients with dementia include:
- Identifying and addressing underlying causes of agitation, such as pain, hunger, thirst, or environmental factors
- Implementing behavioral strategies, including maintaining a consistent daily routine, using redirection techniques, and providing reassurance through calm communication
- Creating a soothing environment by adjusting lighting, reducing noise, and ensuring comfort
- Considering non-pharmacological interventions, such as simulated presence therapy (SPT), massage therapy, animal-assisted interventions, and personally tailored interventions, which have been shown to reduce symptoms of agitation in individuals with severe dementia
- Using SSRIs as a first-line pharmacological treatment, due to their efficacy in reducing agitation and depression, and relatively favorable side effect profile compared to other medications 1.
It is essential to note that typical and atypical antipsychotics can increase the risk of death, probably from cardiac toxicities, and should be used with caution 1. Therefore, SSRIs are the preferred first-line treatment for agitation in patients with dementia, due to their efficacy and relatively favorable safety profile.
From the Research
Treatment Options for Agitation in Dementia Patients
- The first line treatment for agitation in patients with dementia is often a complex decision, involving the consideration of various pharmacologic and non-pharmacologic approaches 2.
- Studies have shown that selective serotonin reuptake inhibitors (SSRIs) such as sertraline and citalopram may be effective in reducing symptoms of agitation in patients with dementia 3.
- Atypical antipsychotics, such as risperidone, have also been found to be effective in managing agitation in dementia patients, although they may be associated with a higher risk of extrapyramidal symptoms and other adverse events 4, 5.
- Typical antipsychotics, such as haloperidol, may also be used to treat agitation in dementia patients, but they are often associated with a higher risk of adverse events, including extrapyramidal symptoms and somnolence 5.
Management of Extrapyramidal Side Effects
- The management of extrapyramidal side effects (EPS) associated with antipsychotic treatment is crucial in the treatment of behavioral and psychological symptoms of dementia (BPSD) 6.
- Certain anti-dementia drugs, such as cholinesterase inhibitors, may potentiate EPS associated with antipsychotic treatment, while others, such as memantine, may reduce EPS induction 6.
- Antidepressant drugs, such as mirtazapine, may also reduce EPS induction, and the activation of certain serotonin receptors may alleviate EPS associated with antipsychotic treatment 6.
Considerations for Treatment
- The treatment of agitation in dementia patients should involve a comprehensive approach, considering the patient's individual needs and circumstances 2.
- The risks and benefits of pharmacologic treatment should be carefully weighed, and non-pharmacologic approaches should be considered as a first line treatment whenever possible 2, 3.
- The selection of antipsychotic medication should be based on the patient's specific symptoms and medical history, as well as the potential risks and benefits of treatment 4, 5.