Buspirone for Vascular Dementia
Buspirone may be considered as a safer alternative to antipsychotics for managing agitation and behavioral disturbances in vascular dementia, though it should be used only after non-pharmacological interventions have been attempted, and evidence supporting its use remains limited.
Treatment Algorithm
Step 1: Non-Pharmacological Interventions First
- Always implement non-pharmacological approaches before any medication, including environmental modifications, structured daily routines, and evaluation for reversible causes of agitation such as pain, hypoxia, urinary retention, and constipation 1, 2.
- Assess the type, frequency, severity, pattern, and timing of agitation symptoms to guide appropriate intervention 2.
Step 2: First-Line Pharmacological Options (If Non-Pharmacological Fails)
- SSRIs are the preferred first-line pharmacological treatment for agitation in dementia, as they significantly improve overall neuropsychiatric symptoms, agitation, and depression 1.
- Trazodone is recommended as the safest first-line option with better tolerability than antipsychotics, starting at 25 mg per day, though caution is needed in patients with premature ventricular contractions 2.
Step 3: Buspirone as an Alternative Option
Evidence Supporting Buspirone
- A retrospective study of 179 dementia patients (including 17.3% with vascular dementia) showed that 68.6% responded to buspirone, with 41.8% being moderately to markedly improved for behavioral disturbances including verbal and physical aggression 3.
- The mean effective dose was 25.7 mg ± 12.50 mg daily, with reported effective doses ranging from 15 to 60 mg/day 3, 4.
- Buspirone is generally well-tolerated and non-sedating, making it a reasonable alternative to benzodiazepines and antipsychotics 4.
Mechanism and Rationale
- Disturbances in serotonergic neurotransmission may underlie anxiety symptoms and agitation in dementia, and buspirone's serotonergic activity may address these symptoms 4.
- Buspirone may be useful for managing irritability, agitation, and aggression in older adult patients with dementia, though additional effectiveness studies are warranted 5.
Medications to Avoid
- Avoid benzodiazepines due to risks of tolerance, addiction, depression, cognitive impairment, and paradoxical agitation 2.
- Use conventional antipsychotics with extreme caution due to high risk of extrapyramidal symptoms and tardive dyskinesia 2.
- Atypical antipsychotics have only small benefits (SMD -0.21 for agitation) but increase risks of somnolence, extrapyramidal symptoms, serious adverse events, and death 1, 6.
Monitoring and Follow-Up
- Regularly assess response to treatment using quantitative measures 2.
- If no clinically significant response occurs after a 4-week trial, taper and withdraw the medication 2.
- Periodically reassess the need for continued medication even in responders, and review the risk/benefit balance if significant side effects develop 2.
Important Caveats
- The evidence for buspirone in dementia comes primarily from open trials, case reports, and one retrospective study; large randomized controlled trials are still needed to confirm its efficacy 7, 3, 4.
- While buspirone showed benefit in some open trials for agitation, it has not been FDA-approved for this indication 7.
- The apparent effectiveness seen in clinical practice may partly reflect the natural fluctuating course of behavioral symptoms, as observed in placebo groups of antipsychotic trials 6.