From the Guidelines
The best management approach for behavioral disturbances and aggression in frontal dementia is to prioritize non-pharmacological interventions, with selective serotonin reuptake inhibitors (SSRIs) being considered for irritability and compulsive behaviors, and atypical antipsychotics used judiciously for severe aggression, as recommended by the most recent guidelines 1.
Key Considerations
- Non-pharmacological strategies should be tried first, including establishing consistent routines, creating a calm environment, identifying and avoiding triggers, using distraction techniques, and providing caregiver education and support.
- When medications are necessary, SSRIs like citalopram (20-40mg daily) or sertraline (50-200mg daily) are typically first-line options for irritability and compulsive behaviors.
- For more severe aggression, atypical antipsychotics such as quetiapine (25-200mg daily) or risperidone (0.25-2mg daily) may be used at the lowest effective dose for the shortest duration possible, with careful monitoring for side effects, as suggested by 1.
- Regular reassessment is essential, as medication needs may change as the disease progresses, and all medications carry risks that must be weighed against potential benefits, particularly in elderly patients with dementia.
Non-Pharmacological Interventions
- Structured and tailored activities that are individualized and aligned to current capabilities and take into account previous roles and interests may be considered, as recommended by 1.
- Simulated presence therapy (SPT), using audio or video recordings prepared by family members or surrogates and including positive experiences from the participant’s past life, can reduce symptoms of agitation in individuals with severe dementia, as noted in 1.
Medication Use
- SSRIs are considered first-line treatments for agitation, as they have been shown to significantly reduce overall neuropsychiatric symptoms, agitation, and depression in individuals with vascular cognitive impairment (VCI), as reported in 1.
- Atypical antipsychotics should be used with caution due to the increased risk of mortality and other adverse effects, as highlighted in 1.
From the Research
Behavioral Disturbances in Frontal Dementia
- Behavioral disturbances, including agitation and aggression, are common in patients with dementia and can be disruptive and life-threatening for patients and surrounding people 2, 3.
- Non-pharmacological interventions should be recommended as a first-line treatment unless symptoms are severe, persistent, or recurrent 2, 4.
- Identifying and addressing predisposing and precipitating factors, such as comorbid medical illnesses, polypharmacy, pain, personal needs, and environmental factors, is critical to successful management 3.
Management Approaches
- Structured behavioral interventions, designed and implemented based on personalization, evidence base, dose and duration, measurement-based care, and environmental factors, can be effective in managing agitation in dementia 5.
- Training of formal caregivers is the most effective intervention for behavioral and psychological symptoms of dementia (BPSD) 4.
- Antidepressants and antipsychotics remain a mainstay of pharmacological treatment for BPSD, but should be prescribed only when behaviors pose a significant safety risk or if the person with dementia is very distressed 2, 4.
Preventing Aggression
- Behavioral strategies to prevent aggression in people with dementia, such as recognizing signs of pain and distress, can decrease caregiver burden and relieve other behavioral disturbances 6.
- Interventions like the Preventing Aggression in Veterans with Dementia (PAVeD) intervention, which teaches caregivers how to recognize signs of pain and distress, may help prevent the development of aggression and pain in people with dementia 6.