From the Guidelines
Non-pharmacological strategies should be considered as the first-line management for agitation and abnormal emotions in dementia patients, with a focus on maintaining a consistent daily routine, creating a calm environment, and using gentle redirection. According to the most recent and highest quality study 1, non-pharmacological strategies are recommended as the first line of management, with a strong recommendation and moderate quality of evidence. This approach is also supported by the American Psychiatric Association practice guideline 1, which emphasizes the importance of assessing the patient's goals and preferences, as well as balancing the potential benefits and harms of any intervention.
Some key non-pharmacological strategies that can be effective in managing agitation and abnormal emotions in dementia patients include:
- Maintaining a consistent daily routine
- Creating a calm environment
- Using gentle redirection
- Identifying triggers that cause distress
- Music therapy
- Reminiscence activities
- Pet therapy
- Structured and tailored activities that are individualized and aligned to current capabilities and take into account previous roles and interests
When medications are needed, antipsychotics like risperidone or quetiapine may be prescribed for severe agitation, but should be used at the lowest effective dose for the shortest time possible due to increased stroke and mortality risks. The Canadian Coalition for Seniors’ Mental Health guidelines, as referenced in 1, provide detailed recommendations for managing behavioral symptoms of dementia, including considerations for pharmacological management. For depression or anxiety symptoms, SSRIs such as sertraline or citalopram may be beneficial, and mood stabilizers like valproate can help with emotional lability. Caregivers should also prioritize their own well-being through respite care, support groups, and self-care practices.
From the Research
Treatments for Agitation and Abnormal Emotion in Dementia Patients
- Non-pharmacologic approaches are recommended as the initial step in treating agitation and aggression in dementia patients, using practical and commonsense strategies 2
- Caregivers and family should be actively involved in the planning and implementation of behavioral plans to improve behavior towards loved ones 2
- Minimizing both medical and non-medical factors that may be contributing to behaviors is essential in treating agitation and aggression in dementia patients 2
Non-Pharmacological Interventions
- Massage therapy, animal-assisted intervention, and personally tailored intervention are associated with more substantial reductions in agitation compared to other interventions and controls 3
- These non-pharmacological interventions can be applied by healthcare professionals for people with dementia during routine care to improve behavior towards loved ones 3
Pharmacologic Management
- Risperidone appears to be effective in controlling agitation in patients with dementia and has a relatively benign adverse-effect profile 4
- The choice of pharmacological options depends on patient comorbidities, specific behavioral and psychological symptoms of dementia (BPSD) presentation, and patient tolerance of medications 5
- Anti-depressants, anti-psychotics, or anti-epileptics in conjunction with cholinesterase inhibitors may be used to manage BPSD manifestations, including severe agitation 5
- Shifting from haloperidol to risperidone for behavioral disturbances in dementia can be safe and effective, particularly at a dose of 0.5 mg/day 6