What are the recommendations for managing agitation in a 79-year-old woman with dementia and anxiety, currently on clonazepam (benzodiazepine) 0.5mg, Remeron (mirtazapine) for depression, Namenda (memantine) 5mg daily, and Guanfacine (alpha-2 adrenergic agonist) 1mg at bedtime?

From the Guidelines

For managing agitation in a 79-year-old woman with dementia and anxiety, I strongly recommend prioritizing non-pharmacological interventions and adjusting her current medication regimen to minimize potential side effects and maximize efficacy. The patient's current medications, including clonazepam 0.5mg, Remeron for depression, Namenda 5mg daily, and Guanfacine 1mg at bedtime, should be reassessed for their impact on her agitation.

• Non-pharmacological interventions should be the first line of approach, including:
  • Maintaining a consistent daily routine
  • Creating a calm environment
  • Identifying and addressing triggers for agitation
  • Using validation therapy
  • Encouraging meaningful activities These approaches can significantly reduce agitation without the risk of medication side effects, as suggested by general clinical guidelines 1.
• Regarding her current medications:
  • Clonazepam should be gradually tapered as benzodiazepines can worsen cognitive function and increase fall risk in elderly patients with dementia, according to the principles outlined in the management of behavior and mood disorders in dementia patients 1.
  • Mirtazapine (Remeron) should be continued as it helps with both depression and sleep, which can reduce agitation.
  • Memantine (Namenda) should be maintained at 5mg daily as it helps with cognitive symptoms and may reduce agitation.
  • Guanfacine should be monitored for effectiveness in managing agitation at bedtime.
• If additional medication is needed for agitation, consider:
  • Low-dose trazodone (25-50mg) at bedtime, as it is recommended for control of problematic delusions, hallucinations, severe psychomotor agitation, and combativeness, with an initial dosage of 25 mg per day and a maximum of 200 to 400 mg per day in divided doses 1.
  • A low-dose atypical antipsychotic like quetiapine (25mg) as needed, though these carry risks that must be carefully weighed, with an initial dosage of 12.5 mg twice daily and a maximum of 200 mg twice daily 1. Regular monitoring for medication effectiveness and side effects is essential, with dose adjustments as needed. Caregiver education and support are also crucial components of successful agitation management in dementia.

From the Research

Managing Agitation in a 79-Year-Old Woman with Dementia and Anxiety

The patient's current medications include clonazepam 0.5mg for anxiety, Remeron for depression, Namenda 5mg daily, and Guanfacine 1mg at bedtime. Given her agitation, refusing medications, and verbal aggression, the following recommendations can be considered:

• Verbal De-escalation: As suggested by the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup 2, a noncoercive approach using verbal de-escalation techniques can be effective in managing agitation. This approach involves verbally engaging the patient, establishing a collaborative relationship, and de-escalating the patient out of the agitated state.
• Pharmacological Management: According to various studies 3, 4, 5, pharmacological management of acute agitation can involve the use of typical antipsychotics, benzodiazepines, or atypical antipsychotics. Haloperidol and lorazepam are commonly used agents, but they can have significant side effects. Atypical antipsychotics like ziprasidone and olanzapine have shown promise in managing acute agitation with fewer adverse effects.
• Inhaled Loxapine: Inhaled loxapine has been shown to be effective in managing agitation associated with schizophrenia or bipolar I disorder in adults 4. However, it requires patient cooperation and carries a black box warning for bronchospasm.
• Key Objectives: When managing agitation, the primary objectives should be to ensure patient and staff safety, help the patient manage emotions and distress, avoid restraint, and avoid coercive interventions that escalate agitation 2.

Some key points to consider when managing agitation in this patient include:

• The patient's current medications and potential interactions
• The need for a noncoercive approach using verbal de-escalation techniques
• The potential benefits and risks of pharmacological management
• The importance of ensuring patient and staff safety
• The need to avoid restraint and coercive interventions

It is essential to weigh the potential benefits and risks of each approach and consider the patient's individual needs and circumstances when developing a management plan.