From the Guidelines
The treatment of agitation in elderly patients with dementia should begin with non-pharmacological approaches, prioritizing strategies that address underlying causes and promote a calm environment, as recommended by the most recent guidelines 1.
Non-Pharmacological Approaches
Before considering medications, it is essential to identify and address underlying causes of agitation, such as pain, infection, constipation, or environmental factors. Implementing behavioral strategies, including:
- Maintaining a consistent routine
- Creating a calm environment
- Using distraction techniques
- Providing reassuring communication can help reduce agitation in elderly patients with dementia.
Pharmacological Interventions
If medication becomes necessary, starting with low doses of selective serotonin reuptake inhibitors (SSRIs) like sertraline (25-100mg daily) is recommended, as they have been found to significantly reduce overall neuropsychiatric symptoms, agitation, and depression in individuals with vascular cognitive impairment (VCI) 1. Atypical antipsychotics like risperidone, quetiapine, or olanzapine may be considered for short durations, but they carry black box warnings for increased mortality in elderly patients with dementia. Cholinesterase inhibitors like donepezil or memantine may help reduce agitation in some patients while treating cognitive symptoms.
Key Considerations
- Regular monitoring for side effects is essential
- Medications should be tapered when symptoms improve
- The goal is to use the lowest effective dose for the shortest duration possible while maximizing quality of life and minimizing harm
- For patients with Lewy body dementia, antipsychotics should be avoided due to sensitivity risks
By prioritizing non-pharmacological approaches and using pharmacological interventions judiciously, healthcare providers can effectively manage agitation in elderly patients with dementia while minimizing the risk of adverse effects.
From the FDA Drug Label
1.4 ZYPREXA IntraMuscular: Agitation Associated with Schizophrenia and Bipolar I Mania 5.1 Elderly Patients with Dementia-Related Psychosis WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS
The treatment options for agitation in elderly patients with dementia are not explicitly stated in the provided drug label. However, olanzapine is indicated for agitation associated with schizophrenia and bipolar I mania.
- Elderly patients with dementia-related psychosis are at increased risk of mortality. The label does not provide direct information on the treatment of agitation in elderly patients with dementia. 2
From the Research
Treatment Options for Agitation in Elderly Patients with Dementia
- Non-pharmacological interventions are preferred for mild symptoms of agitation, while medications are used for severe manifestations 3, 4
- Pharmacological options depend on patient comorbidities, specific behavioral and psychological symptoms of dementia (BPSD) presentation, and patient tolerance of medications 5
- Risperidone appears to be effective in controlling agitation in patients with dementia, with a relatively benign adverse-effect profile 3
- Valproate may be an effective, well-tolerated, and safe treatment for behavioral agitation in elderly patients with dementia 6
- Non-pharmacological interventions such as massage therapy, animal-assisted intervention, and personally tailored intervention have been shown to be effective in reducing agitation in people with dementia 4
Pharmacological Management
- Anti-depressants, anti-psychotics, or anti-epileptics may be used in conjunction with cholinesterase inhibitors to manage BPSD, including agitation 5
- The choice of pharmacological options should be based on patient-specific factors, such as comorbidities and tolerance of medications 5
Non-Pharmacological Interventions
- Massage therapy, animal-assisted intervention, and personally tailored intervention have been ranked as the most effective non-pharmacological interventions for reducing agitation in people with dementia 4
- These interventions can be used in clinical practice to ameliorate agitation in people with dementia 4