What is the first line treatment for agitation in dementia?

First-Line Treatment for Agitation in Dementia

Non-pharmacological interventions should be used as the first-line treatment for agitation in patients with dementia, including identifying and addressing underlying causes such as untreated pain, infections, constipation, and environmental triggers. 1

Assessment of Agitation

Before initiating any treatment, a thorough assessment is essential to:

• Identify potential triggers of agitation including pain, medications, and psychosocial stressors 2
• Rule out iatrogenic causes and treatable contributing factors 2
• Evaluate for drug toxicity, medical conditions, psychiatric issues, or environmental problems that may underlie behavioral changes 2

Tools like the Neuropsychiatric Inventory Questionnaire (NPI-Q) can help assess the severity of agitation and caregiver distress 2.

Non-Pharmacological Interventions

Implement these strategies first:

• Personalized approaches:

  • Therapy with simulated presence (using audio/video recordings from family members)
  • Activities based on previous preferences and interests
  • "Three R's" technique: repeating, reassuring, and redirecting 1

• Environmental modifications:

  • Create a calm, familiar environment
  • Ensure adequate lighting
  • Reduce excessive stimulation 1
  • Maintain consistent routines 1

• Additional non-pharmacological options:

  • Person-centered care (shown to decrease symptomatic and severe agitation for up to 6 months) 3
  • Communication skills training 3
  • Massage therapy
  • Animal-assisted interventions 1
  • Structured music therapy 3
  • Sensory interventions for clinically significant agitation 3

• Caregiver support:

  • Education and support for caregivers can significantly reduce behavioral disturbances 1
  • Consider registering wandering-risk patients in the Alzheimer's Association Safe Return Program 1

Pharmacological Interventions

If non-pharmacological approaches are insufficient and agitation causes significant distress or risk, consider medications in this order:

1. First-line pharmacological option: Selective Serotonin Reuptake Inhibitors (SSRIs)

   • Shown to significantly reduce neuropsychiatric symptoms, agitation, and depression 1
   • Citalopram has encouraging preliminary evidence 4

2. FDA-approved option for Alzheimer's dementia agitation:

   • Brexpiprazole 1

3. Alternative options:

   • Trazodone (starting at 25 mg/day, maximum 200-400 mg/day) 1
   • Memantine (has encouraging preliminary evidence) 4, 1
   • Carbamazepine (has encouraging preliminary evidence) 4, 1

4. Atypical antipsychotics (only when symptoms are severe, dangerous, or cause significant distress):

   • Use low doses of risperidone, quetiapine, or olanzapine 1
   • Important caution: Carry FDA black box warnings for increased mortality (1.6-1.7 times higher risk) in elderly patients with dementia 1
   • Benefits are modest and significant only in short-term treatment (6-12 weeks) of aggression 5

Medication Management Principles

• Start with the lowest effective dose for the shortest duration
• Assess response using quantitative measures
• Consider tapering within 3-6 months to determine lowest effective maintenance dose 1
• Avoid typical antipsychotics due to significant side effects and risk of tardive dyskinesia 1
• Use benzodiazepines (like lorazepam) only for acute anxiety episodes, not regularly, due to risks of tolerance, addiction, cognitive impairment, and paradoxical agitation 1

Common Pitfalls to Avoid

1. Skipping non-pharmacological approaches: Many clinicians jump to medications before adequately trying behavioral interventions 6

2. Prolonged antipsychotic use: Benefits are limited in longer-term therapy but risks continue 5

3. Inadequate assessment: Failing to identify underlying causes like pain, infection, or medication side effects that could be directly addressed 2

4. Inconsistent implementation: Non-pharmacological interventions require consistent application and staff training to be effective 3

5. Overlooking caregiver burden: Caregiver education and support are essential components of successful management 1