What are the recommended medications for managing aggressive behaviors in dementia?

Recommended Medications for Aggressive Behaviors in Dementia

Non-pharmacological interventions must be attempted first, and medications should only be used when behavioral strategies fail and there is significant risk of harm to the patient or others. 1

First-Line Approach: Non-Pharmacological Management

Before considering any medication, you must:

• Investigate and treat underlying medical causes including pain, urinary tract infections, constipation, hypoxia, and pneumonia 2, 1
• Implement environmental modifications such as structured routines, reduced overstimulation, adequate lighting, and ensuring patient comfort 1, 3
• Use ABC charting (antecedent-behavior-consequences) to identify triggers and patterns over several days 2, 3
• Modify communication approaches using calm tones, simple one-step commands, and avoiding confrontational language 3

Pharmacological Management Algorithm

For Severe Agitation with Psychotic Features (Hallucinations/Delusions)

Atypical antipsychotics are the preferred first-line pharmacological option when medications become necessary:

• Risperidone (Risperdal): Start 0.25 mg at bedtime, maximum 2-3 mg/day in divided doses; extrapyramidal symptoms may occur at 2 mg/day 4
• Olanzapine (Zyprexa): Start 2.5 mg at bedtime, maximum 10 mg/day in divided doses; generally well tolerated but less effective in patients over 75 years 4, 1
• Quetiapine (Seroquel): Start 12.5 mg twice daily, maximum 200 mg twice daily; more sedating with risk of transient orthostasis 4

Critical warnings about antipsychotics:

• Use only at the lowest effective dose for the shortest possible duration 1
• Associated with increased mortality, stroke risk, falls, QT prolongation, pneumonia, and metabolic effects 1
• Evaluate ongoing use daily with in-person examination 1
• Discuss risks versus benefits with patient and surrogate decision maker before initiating 1
• Monitor closely and attempt dose reduction or discontinuation after symptoms stabilize 2

For Severe Agitation WITHOUT Psychotic Features

Mood stabilizers/antiagitation drugs are useful alternatives:

• Divalproex sodium (Depakote): Start 125 mg twice daily, titrate to therapeutic blood level (40-90 mcg/mL); generally better tolerated than other mood stabilizers; monitor liver enzymes and coagulation parameters 4
• Trazodone (Desyrel): Start 25 mg/day, maximum 200-400 mg/day in divided doses; use with caution in patients with premature ventricular contractions 4
• Carbamazepine (Tegretol): Start 100 mg twice daily, titrate to therapeutic level (4-8 mcg/mL); monitor CBC and liver enzymes regularly; has problematic side effects 4

For Chronic Agitation (Non-Emergency)

SSRIs are recommended for chronic agitation:

• Initiate at low dose and titrate to minimum effective dose 1
• Assess response with quantitative measures after 4 weeks of adequate dosing; taper and withdraw if no clinically significant response 1
• Sertraline (Zoloft): Start 25-50 mg/day, maximum 200 mg/day; well tolerated with less effect on metabolism of other medications 4
• Citalopram (Celexa): Start 10 mg/day, maximum 40 mg/day; well tolerated though some patients experience nausea and sleep disturbances 4

For Mild to Moderate Agitation with Anxiety

Buspirone (BuSpar): Start 5 mg twice daily, maximum 20 mg three times daily; useful only for mild to moderate agitation; may take 2-4 weeks to become effective 4

Medications to AVOID

Do NOT use the following:

• Typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy; associated with 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 4, 2
• Thioridazine, chlorpromazine, or trazodone for behavioral symptoms in frontotemporal dementia 2
• Benzodiazepines for routine use; cause tolerance, addiction, depression, cognitive impairment, and paradoxical agitation in 10% of elderly patients 4, 1
• Medications with significant anticholinergic effects which worsen cognitive symptoms 2, 3

Monitoring and Reassessment Protocol

• Evaluate response within 30 days; if minimal improvement, refer to mental health specialist 2, 3
• Review need for medication at every visit and taper if no longer indicated 1
• Consider tapering after 6 months of symptom stabilization 2, 3
• Periodically reassess even with positive response, as neuropsychiatric symptoms fluctuate over the course of dementia 2, 1

Common Pitfalls to Avoid

• Do not continue antipsychotics indefinitely; approximately 47% of patients continue receiving them after discharge without clear indication 1
• Do not use antipsychotics for mild agitation; reserve for severe symptoms that are dangerous or cause significant distress 1
• Do not rely solely on medications without implementing non-pharmacological strategies 2, 3
• Do not fail to investigate underlying medical causes before attributing behavior to dementia alone 2, 3