From the Guidelines
Antipsychotic medications are indicated for agitation in patients with dementia, particularly in individuals with dangerous agitation or psychosis, as they can minimize the risk of violence, reduce patient distress, improve patient’s quality of life, and reduce caregiver burden 1.
Key Considerations
- The use of antipsychotic medications in individuals with dementia should be based on an initial assessment and an understanding of the goals and preferences of the patient, with input from family or others involved with the patient 1.
- Decisions about treatment should balance the potential benefits and harms of a particular intervention, as antipsychotics are associated with clinically significant adverse effects, including mortality 1.
- The benefits of antipsychotic medications are at best small, whether assessed through placebo-controlled trials, head-to-head comparison trials, or discontinuation trials 1.
Medication Options
- Cholinesterase inhibitors should not be discontinued in individuals who currently have clinically meaningful psychotic symptoms, agitation, or aggression until these symptoms have stabilized, unless these symptoms appear to have been worsened by the initiation of a ChEI or an increase in ChEI dose 1.
- Memantine may be considered for individuals with Alzheimer’s disease, Parkinson’s disease dementia, Lewy body dementia, or vascular dementia, but should be discontinued if there has been a clinically meaningful worsening of dementia or no clinically meaningful benefit was observed at any time during treatment 1.
From the Research
Medications for Agitation in Dementia Patients
The following medications are indicated for agitation in patients with dementia:
- Citalopram and escitalopram, which are selective serotonin reuptake inhibitors (SSRIs) 2
- Risperidone, an antipsychotic medication 3, 4
- Aripiprazole and quetiapine, which are also antipsychotic medications 3
- Carbamazepine, an anticonvulsant medication 3, 5
- Gabapentin, an anticonvulsant medication 3
- Prazosin, an alpha-adrenergic blocker 3
Treatment Algorithms
A sequential drug treatment algorithm for agitation and aggression in Alzheimer's and mixed dementia has been proposed, which includes:
- Baseline assessment and discontinuation of potentially exacerbating medications
- Sequential trials with risperidone, aripiprazole or quetiapine, carbamazepine, citalopram, gabapentin, and prazosin
- Titration schedules with adjustments for frailty 3
Novel Treatments
Novel treatments, such as cannabinoids, lithium, non-steroidal anti-inflammatory drugs, analgesics, narcotics, and newer antiepileptic drugs, may provide a safer alternative treatment option for the management of agitation and aggression in AD patients 6