What is the recommended treatment for acute anxiety in dementia?

Treatment for Acute Anxiety in Dementia

For acute anxiety in dementia, a stepped approach is recommended, starting with non-pharmacological interventions first, followed by short-term use of SSRIs if needed, with benzodiazepines reserved only for severe, acute episodes due to their significant risks. 1

First-Line: Non-Pharmacological Interventions

Non-pharmacological approaches should be attempted before medication:

• Identify and address underlying causes - Look for pain, discomfort, environmental triggers, or unmet needs that may be causing anxiety 1
• Music therapy - Most effective non-pharmacological intervention for anxiety in dementia 2
• Physical activity/exercise - Second most effective non-pharmacological approach 2
• Behavioral strategies - Use the "three R's" approach (repeat, reassure, and redirect) to manage anxiety episodes 1
• Environmental modifications - Reduce excess stimulation, maintain consistent routines, and provide a safe, familiar environment 1
• Cognitive behavioral therapy (CBT) - Modified CBT approaches have shown promise for anxiety in mild to moderate dementia 3
• Caregiver education - Teaching caregivers effective communication techniques and behavioral management strategies 1

Second-Line: Pharmacological Interventions

When non-pharmacological approaches are insufficient:

SSRIs (First-choice medications)

• Citalopram (Celexa) - Start at 10 mg daily, maximum 40 mg daily 1
• Sertraline (Zoloft) - Start at 25-50 mg daily, maximum 200 mg daily 1
• Paroxetine (Paxil) - Start at 10 mg daily, maximum 40 mg daily 1

SSRIs are preferred because:

• They significantly improve overall neuropsychiatric symptoms and agitation in dementia 1
• They have minimal anticholinergic side effects compared to other options 1
• They are considered first-line treatments for agitation in dementia 1

Non-Benzodiazepine Anxiolytics

• Buspirone (BuSpar) - Start at 5 mg twice daily, maximum 20 mg three times daily 1
  • Only useful for mild to moderate agitation
  • May take 2-4 weeks to become effective
  • Less sedating than benzodiazepines

Third-Line (For Severe, Acute Episodes Only)

Benzodiazepines (Use with extreme caution)

• Lorazepam (Ativan), Oxazepam (Serax) - Short-acting agents preferred 1
• Important cautions:
  • Use lowest possible dose for shortest duration (ideally less than 2 weeks) 4
  • Significant risks in elderly dementia patients: sedation, cognitive impairment, falls, paradoxical agitation 1, 4
  • Regular use leads to tolerance, addiction, and worsening cognitive impairment 1
  • Beers Criteria recommends avoiding if possible in elderly patients 1

Medications to Avoid

• Antipsychotics - Both typical and atypical antipsychotics carry FDA black box warnings for increased mortality risk in dementia patients 1
• Anticholinergic medications - Worsen cognition and can increase confusion 1
• Long-acting benzodiazepines (e.g., diazepam) - Accumulate in elderly patients and increase risk of adverse effects 1, 4

Implementation Algorithm

1. Assess for underlying causes (pain, infection, environmental factors)
2. Implement non-pharmacological interventions (music therapy, exercise, behavioral strategies)
3. If insufficient response after 1-2 weeks, consider SSRI (citalopram or sertraline)
4. For severe, acute anxiety that poses immediate safety risk, short-term lorazepam may be considered while initiating other treatments
5. Regularly reassess medication need and attempt gradual discontinuation when symptoms stabilize

Common Pitfalls to Avoid

• Rushing to medication before trying non-pharmacological approaches 1
• Using benzodiazepines as first-line treatment 1
• Continuing medications longer than necessary without reassessment 1
• Overlooking underlying causes of anxiety that could be addressed without medication 1
• Failing to recognize that anxiety in dementia is often existential in nature and related to loss 5