What is the best approach to treat agitation associated with dementia?

Treatment of Agitation Associated with Dementia

Non-pharmacological interventions should be considered as first-line management for agitation in dementia before considering any medication. 1, 2

Assessment and Identification of Triggers

Before initiating treatment, a thorough assessment is essential to identify potential triggers of agitation:

• Evaluate for underlying causes:

  • Pain or discomfort
  • Infections (particularly urinary tract infections)
  • Medication side effects or interactions
  • Constipation
  • Environmental triggers (noise, lighting, unfamiliar surroundings)
  • Psychosocial stressors

• Use validated assessment tools:

  • Neuropsychiatric Inventory Questionnaire (NPI-Q) to assess severity and caregiver distress 2
  • Antecedent-behavior-consequences (ABC) charting to systematically track agitation over several days 1

First-Line: Non-Pharmacological Interventions

Non-pharmacological approaches should be implemented first and include:

1. Individualized activities based on preferences and abilities:

   • Structured and tailored activities aligned to current capabilities 1
   • Personalized activities based on previous interests 2
   • Montessori activities for older adults with severe symptoms 1

2. Environmental modifications:

   • Create a calm, familiar environment
   • Ensure adequate lighting
   • Reduce excessive stimulation 2
   • Maintain consistent routines

3. Communication strategies:

   • "Three R's" technique: Repeating, Reassuring, and Redirecting 2
   • Person-centered care approaches 3
   • Communication skills training for caregivers 3

4. Sensory interventions:

   • Simulated presence therapy
   • Massage therapy
   • Animal-assisted interventions 2
   • Music therapy by protocol 3

5. Caregiver support and education:

   • Training in behavioral management techniques
   • Support to reduce caregiver distress 2

Evidence shows these non-pharmacological approaches can significantly reduce agitation. A randomized controlled trial demonstrated that individualized interventions addressing unmet needs produced significant decreases in physical non-aggressive and verbal agitation while increasing pleasure and interest 4.

Second-Line: Pharmacological Interventions

If non-pharmacological interventions are insufficient and agitation causes significant distress or risk, consider medications:

1. First pharmacological option:

   • Selective Serotonin Reuptake Inhibitors (SSRIs)
     • Citalopram (with attention to QT interval prolongation) 2, 5

2. Second-line options:

   • Brexpiprazole (FDA-approved specifically for agitation in Alzheimer's dementia) 2
   • Trazodone (starting at 25 mg/day, maximum 200-400 mg/day) 2, 5

3. Third-line options (use with caution due to significant risks):

   • Atypical antipsychotics at low doses (only when symptoms are severe, dangerous, or cause significant distress)
     • Risperidone
     • Quetiapine
     • Olanzapine 2
   • Important warning: Antipsychotics carry FDA black box warnings for increased mortality (1.6-1.7 times) in elderly patients with dementia 2

4. Other considerations:

   • Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) for mild to moderate dementia
   • Memantine for moderate to severe dementia 2
   • Gabapentin as a third-line agent when other options have failed 2

Treatment Principles and Monitoring

• Start with the lowest effective dose for the shortest duration
• Assess response using quantitative measures
• Consider tapering medications within 3-6 months to determine the lowest effective maintenance dose 2
• Avoid benzodiazepines except for acute anxiety episodes (risk of tolerance, addiction, cognitive impairment, and paradoxical agitation) 2
• Avoid typical antipsychotics due to significant side effects and risk of tardive dyskinesia 2

Special Considerations

• Pain management should be addressed as untreated pain may contribute to agitation, though evidence for pain treatment reducing agitation is inconsistent 6
• For severe, refractory cases not responding to medication management, electroconvulsive therapy (ECT) may be considered 2
• Document comprehensive treatment decisions and discussions with patient (if feasible) and surrogate decision-makers 2

Pitfalls to Avoid

• Rushing to pharmacological interventions before thoroughly trying non-pharmacological approaches
• Failing to identify and address underlying causes of agitation
• Using antipsychotics as first-line treatment
• Continuing medications without regular reassessment of need
• Using benzodiazepines for long-term management
• Overlooking caregiver education and support