What are the treatment options for dementia-related agitation and anxiety?

Treatment Options for Dementia-Related Agitation and Anxiety

Non-pharmacological approaches should be the first-line treatment for dementia-related agitation and anxiety, with pharmacological interventions reserved for cases where these strategies are ineffective or when there is imminent danger. 1

Non-Pharmacological Interventions (First-Line)

Environmental Modifications

• Reduce excessive stimulation and noise
• Ensure adequate lighting (reduce nighttime light)
• Maintain comfortable room temperature
• Create structured bedtime routines 1

Activity-Based Interventions

• Increase daytime physical and social activities
• Reduce time spent in bed during the day
• Maintain consistent sleep-wake schedules
• Ensure 30+ minutes of daily sunlight exposure 1
• Implement light therapy (3,000-5,000 lux for 2 hours in the morning) to decrease daytime napping and increase nighttime sleep 1

Communication and Caregiver Support

• Use person-centered care approaches (shown to decrease symptomatic and severe agitation for up to 6 months) 2
• Provide communication skills training for caregivers 2
• Use the DICE approach (Describe, Investigate, Create, Evaluate) as a structured framework for managing neuropsychiatric symptoms 1

Pharmacological Interventions (Second-Line)

When non-pharmacological approaches fail to adequately control symptoms, consider medication in the following order:

First-Line Medications

• Acetaminophen: Start with the lowest effective dose for pain that may be causing agitation 1
• SSRIs (citalopram, sertraline): Preferred for behavioral symptoms with minimal anticholinergic effects 1
• Cholinesterase inhibitors (donepezil, rivastigmine, galantamine): May improve behavioral symptoms including sundowning 1
• Melatonin: Consider for circadian rhythm regulation, particularly in patients with known melatonin deficiency 1

Second-Line Medications (Use with Caution)

• Trazodone: For agitation in dementia (start at 25 mg/day, maximum 200-400 mg/day) 1
• Gabapentin: For behavioral and psychological symptoms of dementia (BPSD) 1

Third-Line Medications (Significant Risks)

• Antipsychotics: Show modest efficacy but have significant risks including increased mortality in elderly patients with dementia 1
  • Quetiapine: For agitation in Lewy Body Dementia (use lowest effective dose for shortest duration) 1
  • Brexpiprazole: For agitation in Alzheimer's dementia 1

Assessment and Monitoring

• Regularly assess agitation using quantitative measures like Neuropsychiatric Inventory Questionnaire (NPI-Q) 1
• Evaluate for underlying pain that may present as agitation rather than relying solely on self-reporting 1
• Review current medications that may be contributing to agitation 1
• Assess for medication overuse that could be worsening symptoms 1

Important Considerations and Pitfalls

• Avoid medications that may worsen cognition (opioids, high-dose anticholinergics, sedatives) 1
• Use NSAIDs with extreme caution due to GI and renal risks in elderly patients 1
• Antipsychotics have black box warnings for increased risk of stroke and mortality in elderly patients with dementia 3
• Document discussions about risks and benefits of medications with patients and family members 3
• Be aware that agitation prevalence ranges from 30-50% across different types of dementia, making it the third most common neuropsychiatric symptom after apathy and depression 4

Special Circumstances

• For "sundowning" (late afternoon/evening agitation), focus on environmental modifications, consistent routines, and light therapy 1, 5
• For nursing home residents (where agitation prevalence reaches 80%), adapted dementia care mapping has shown effectiveness 4, 2
• For acute agitation requiring immediate intervention, risperidone may be considered in patients with low risk of extrapyramidal symptoms, but should be used at low doses with careful monitoring 5