What medication is used to treat acute agitation in patients with dementia?

Treatment of Acute Agitation in Patients with Dementia

For acute agitation in patients with dementia, nonpharmacological interventions should be tried first, but when medication is necessary, low-dose atypical antipsychotics such as risperidone may be considered with careful risk assessment. 1

Assessment and Initial Approach

• Thoroughly assess the type, frequency, severity, pattern, and timing of agitation symptoms to guide appropriate intervention 1
• Evaluate for potentially modifiable contributors to agitation, particularly pain, which is often undertreated and can manifest as agitation in dementia patients 1
• Use quantitative measures to assess the severity of agitation and response to treatment 1

First-Line: Nonpharmacological Interventions

• Person-centered nonpharmacological interventions should be implemented before considering medication 1
• Develop individualized care plans addressing environmental factors, sensory needs, and personal preferences 1
• Implement environmental modifications, such as reducing noise and providing appropriate lighting 1
• Establish structured daily routines and meaningful activities tailored to the person's interests and abilities 1

Pharmacological Management

When to Consider Medication

• Medications should only be used when symptoms are severe, dangerous, or causing significant distress 1
• Antipsychotic medications may be considered when nonpharmacological interventions have failed 1
• The potential benefits of medication must outweigh the risks 1, 2

Medication Options

• Low-dose atypical antipsychotics, particularly risperidone, are most commonly used for acute agitation in dementia 1, 3, 2
• Atypical antipsychotics probably reduce agitation slightly (SMD -0.21,95% CI -0.30 to -0.12) based on moderate-certainty evidence 2
• Risperidone appears effective in controlling agitation in patients with dementia and has a relatively benign adverse effect profile compared to typical antipsychotics 3
• Citalopram (an SSRI) can be considered as an alternative to antipsychotics, with attention paid to potential QT interval prolongation 4
• Cholinesterase inhibitors may help reduce agitation in some patients and should be considered for those with Alzheimer's disease 5, 4

Dosing and Administration

• Start at the lowest possible dose and titrate slowly to the minimum effective dose 1
• For risperidone, a low initial dosage that is gradually adjusted upward is recommended 3

Monitoring and Safety Considerations

• Atypical antipsychotics increase the risk of somnolence (RR 1.93,95% CI 1.57 to 2.39) and extrapyramidal symptoms (RR 1.39,95% CI 1.14 to 1.68) 2
• These medications are also associated with increased risk of serious adverse events (RR 1.32,95% CI 1.09 to 1.61) and potentially death (RR 1.36,95% CI 0.90 to 2.05) 2
• Discuss risks and benefits with the patient (if possible) and surrogate decision-makers 1
• Monitor closely for adverse effects 1
• Regularly assess response to treatment using quantitative measures 1
• If no clinically significant response occurs after a 4-week trial of an adequate antipsychotic dose, taper and withdraw the medication 1
• For patients who respond positively, periodically reassess the need for continued medication 1

Important Caveats

• The apparent effectiveness of antipsychotics seen in daily practice may be partly explained by the natural course of symptoms, as observed in placebo groups 2
• Benefits of antipsychotics are modest at best, with small effect sizes in clinical trials 6, 2
• The American Psychiatric Association notes that in clinical trials, the benefits of antipsychotic medications are at best small 6
• Consider that there is no "one-size fits all" approach to agitation in dementia due to patient heterogeneity and comorbidities 4