What is the appropriate medication for agitation in elderly patients with dementia?

From the Guidelines

For managing agitation in elderly patients with dementia, non-pharmacological approaches should be tried first, including identifying and addressing underlying causes such as pain, hunger, or environmental factors. When medications are necessary, the most recent and highest quality study 1 suggests that SSRIs, such as citalopram, are considered first-line treatments for agitation due to their ability to reduce overall neuropsychiatric symptoms, agitation, and depression in individuals with VCI. The recommended dosage for citalopram is 10-20mg daily, which has fewer side effects compared to other options. Alternative options include low-dose atypical antipsychtics like quetiapine (starting at 12.5-25mg daily), risperidone (0.25-0.5mg daily), or olanzapine (2.5-5mg daily) for short durations (generally less than 12 weeks), but these medications carry black box warnings for increased mortality in elderly dementia patients. All medications should be started at the lowest possible dose, with careful monitoring for side effects including sedation, falls, extrapyramidal symptoms, and cardiovascular effects. Regular reassessment is essential, with attempts to taper and discontinue medication once behavior stabilizes. The goal is to use the lowest effective dose for the shortest duration possible while maintaining the patient's quality of life and safety. Non-pharmacological strategies, such as simulated presence therapy, massage therapy, animal-assisted interventions, and personally tailored interventions, can also be effective in reducing symptoms of agitation in individuals with severe dementia. These approaches should be considered as first-line management, as recommended by the Canadian stroke best practice recommendations 1 and 1.

From the FDA Drug Label

WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS 5.1 Elderly Patients with Dementia-Related Psychosis

Medication for agitation in elderly with dementia: Olanzapine is not recommended due to the increased risk of mortality in elderly patients with dementia-related psychosis 2.

• Key consideration: The warning indicates a significant risk associated with the use of olanzapine in this population.
• Clinical decision: Alternative treatments should be considered for agitation in elderly patients with dementia.

From the Research

Medication Options for Agitation in Elderly with Dementia

• The choice of pharmacological options for agitation in elderly with dementia depends on patient comorbidities, specific behavioral and psychological symptoms of dementia (BPSD) presentation, and patient tolerance of medications 3.
• Low- to moderate-quality evidence supports the use of anti-depressants, anti-psychotics, or anti-epileptics in conjunction with cholinesterase inhibitors for managing BPSD, including agitation 3.
• Acetylcholinesterase inhibitors and memantine can be initiated to enhance cognition, and trazodone can be used to manage insomnia or sundowning 4.
• Citalopram can be initiated for agitation, with attention paid to potential prolongation of the QT interval, and low doses of atypical antipsychotics such as risperidone or quetiapine can be effective after considering potential adverse effects 4.

Non-Pharmacological Interventions for Agitation in Dementia

• Non-pharmacological interventions, such as massage therapy, animal-assisted intervention, and personally tailored intervention, have been shown to be effective in reducing agitation in people with dementia 5.
• Person-centred care, communication skills training, and adapted dementia care mapping have also been found to decrease symptomatic and severe agitation in care homes 6.
• Activities and music therapy, as well as sensory intervention, have been shown to decrease overall agitation and clinically significant agitation 6.
• Aromatherapy and light therapy have not demonstrated efficacy in reducing agitation 6.

Considerations for Managing Agitation in Dementia

• Identifying and addressing medical and environmental precipitants of agitation remains a priority 4.
• There is no "one-size fits all" approach to managing agitation in dementia, and treatment options should be tailored to the individual patient's needs and comorbidities 4.
• Healthcare professionals should be encouraged to apply promising non-pharmacological interventions, such as massage therapy and animal-assisted intervention, for people with dementia during routine care 5.