How to manage nighttime agitation and aggression in a patient with dementia?

Management of Nighttime Agitation and Aggression in Dementia

Start immediately with non-pharmacological interventions targeting nighttime-specific triggers, and if behavioral approaches fail after 24-48 hours and the patient poses imminent danger, initiate an SSRI (citalopram 10 mg or sertraline 25-50 mg daily) as first-line pharmacological treatment, reserving low-dose haloperidol (0.5 mg) only for severe acute episodes with risk of harm. 1

Immediate Non-Pharmacological Interventions (Must Be Attempted First)

Environmental modifications specific to nighttime agitation:

• Optimize lighting during evening hours to prevent sundown syndrome, as lower daytime light levels are associated with increased nighttime awakenings even after controlling for dementia severity 2
• Ensure adequate bright light exposure (3,000-5,000 lux) for 2 hours during morning/daytime to consolidate nighttime sleep and decrease agitated behavior 2
• Reduce nighttime noise and light in the sleeping environment to minimize awakenings 2
• Establish predictable evening routines and simplify nighttime care tasks 1

Address underlying medical triggers before any medication:

• Systematically investigate pain, urinary tract infections, constipation, and dehydration as these are major contributors to nighttime behavioral disturbances in patients who cannot verbally communicate discomfort 1
• Review all medications for anticholinergic effects that worsen agitation 1
• Ensure adequate pain management before attempting evening care activities 1

Communication and behavioral strategies:

• Use calm tones, simple one-step commands, and gentle touch rather than complex instructions 1
• Allow adequate time for processing before expecting responses 1
• Question whether nighttime care activities are truly necessary or can be deferred to when the patient is calmer 1
• Use ABC charting (antecedent-behavior-consequence) to identify specific nighttime triggers 1

Structured Daytime Activities to Prevent Nighttime Agitation

• Increase daytime physical and social activities with structured routines to consolidate the sleep-wake cycle 2
• Ensure at least 30 minutes of sunlight exposure daily 2
• Reduce daytime napping and time in bed to increase sleep pressure at night 2
• A multicomponent approach combining increased sunlight, physical activity, social conversation, and reduced daytime bed rest has been shown to decrease nighttime sleep disruption 2

Pharmacological Treatment (Only After Behavioral Interventions Fail)

First-line chronic treatment (if agitation persists beyond 24-48 hours):

• Initiate citalopram 10 mg daily (maximum 40 mg/day) OR sertraline 25-50 mg daily (maximum 200 mg/day) as preferred options for chronic nighttime agitation 1, 3
• SSRIs significantly reduce overall neuropsychiatric symptoms, agitation, and depression in dementia patients 1
• Assess response using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) within 4 weeks 1
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw 1

Alternative if SSRIs fail or not tolerated:

• Trazodone 25 mg at bedtime (maximum 200-400 mg/day in divided doses) may be considered, though use caution due to orthostatic hypotension risk 1, 3

Acute severe agitation with imminent risk of harm:

• Low-dose haloperidol 0.5-1 mg orally or subcutaneously only when patient is severely agitated, threatening substantial harm, and behavioral interventions have failed 1
• Maximum 5 mg daily in elderly patients 1
• Use at lowest effective dose for shortest possible duration with daily reassessment 1

Critical Safety Warnings and Monitoring

Before initiating any antipsychotic, you must:

• Discuss with patient (if feasible) and surrogate decision-maker the 1.6-1.7 times increased mortality risk compared to placebo, cardiovascular effects, cerebrovascular adverse reactions, falls risk, and QT prolongation 1
• Document that behavioral interventions were attempted and failed 1
• Confirm patient is severely agitated and threatening substantial harm 1

Monitoring requirements:

• Daily in-person examination to evaluate ongoing need when using antipsychotics 1
• Monitor for extrapyramidal symptoms, falls, metabolic changes, QT prolongation, and cognitive worsening 1
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine 1

What NOT to Use

• Avoid benzodiazepines as first-line treatment as they increase delirium incidence and duration, and cause paradoxical agitation in approximately 10% of elderly patients 1
• Do not use typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line chronic therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use 1
• Avoid anticholinergic medications like diphenhydramine which worsen agitation in dementia 1
• Do not newly prescribe cholinesterase inhibitors to prevent or treat agitation as they are associated with increased mortality 1

Reassessment and Discontinuation

• Review need for continued medication at every visit and taper if no longer indicated 1
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—avoid inadvertent chronic use 1
• Even with positive response to SSRIs, periodically reassess need for continued medication 1
• Consider tapering after 9 months to reassess necessity 1

Common Pitfalls to Avoid

• Do not skip non-pharmacological interventions—they have substantial evidence for efficacy without mortality risks associated with medications 1
• Do not use antipsychotics for mild agitation—reserve them only for severe, dangerous symptoms 1
• Do not continue antipsychotics indefinitely without regular reassessment 1
• Do not assume all nighttime agitation requires medication—many cases respond to environmental modifications and addressing underlying medical causes 2, 1