What is the best approach to manage a patient with early onset dementia, major depressive disorder (MDD), insomnia, psychosis, and trichotillomania, who is currently not on any psychiatric medications but is taking blood pressure medication, and has a history of taking various medications?

Management of Early Onset Dementia with Psychosis, Anxiety, and Behavioral Disturbances

Start with an SSRI (citalopram 10 mg daily or sertraline 25-50 mg daily) as your first-line pharmacological treatment for this patient's chronic agitation, paranoia, and anxiety, given once in the morning as requested. 1

Immediate Assessment Before Starting Medication

Before prescribing any psychotropic medication, you must systematically investigate and treat reversible causes that commonly drive behavioral symptoms in dementia patients who cannot verbally communicate discomfort 1:

• Screen for infections, particularly urinary tract infections and pneumonia, as these are major contributors to paranoia and agitation 1, 2
• Assess for pain, which is frequently undertreated and manifests as behavioral disturbances 1, 2
• Check for dehydration, constipation, and urinary retention 1, 2
• Review all medications for anticholinergic effects or other agents that may worsen confusion and psychosis 3, 2

First-Line Pharmacological Treatment: SSRIs

For chronic agitation with paranoia and anxiety in dementia, SSRIs are the preferred pharmacological option 1:

Specific Dosing Recommendations

• Citalopram: Start 10 mg every morning, maximum 40 mg/day 4, 1

  • Well tolerated, though some patients experience nausea and sleep disturbances 4
  • Can be given once daily in the morning as you requested 4

• Sertraline: Start 25-50 mg every morning, maximum 200 mg/day 4, 1

  • Well tolerated with less effect on metabolism of other medications 4
  • Also suitable for once-daily morning dosing 4

Timeline and Monitoring

• Assess response within 4 weeks using quantitative measures like the Cohen-Mansfield Agitation Inventory or NPI-Q 1
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 1
• Even with positive response, periodically reassess the need for continued medication 1

When SSRIs Are Insufficient: Second-Line Options

If SSRIs fail or are not tolerated after an adequate 4-week trial, consider these alternatives 4, 1:

Trazodone (Alternative Mood Stabilizer)

• Start 25 mg at bedtime, maximum 200-400 mg/day in divided doses 4
• Use with caution in patients with premature ventricular contractions 4
• Can be given in morning if needed, though typically more sedating 4

Divalproex Sodium (For Severe Agitation)

• Start 125 mg twice daily (can give both doses in morning if absolutely necessary, though not ideal) 4
• Titrate to therapeutic blood level (40-90 mcg/mL) 4
• Generally better tolerated than other mood stabilizers 4
• Monitor liver enzymes, platelets, PT/PTT as indicated 4

Reserve Antipsychotics for Severe, Dangerous Symptoms Only

Antipsychotics should only be used when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions plus SSRIs have failed 1:

Critical Safety Discussion Required

Before initiating any antipsychotic, you must discuss with the patient (if feasible) and surrogate decision maker 1:

• Increased mortality risk (1.6-1.7 times higher than placebo) 1
• Cardiovascular effects and cerebrovascular adverse reactions 1
• Risk of falls, metabolic changes, and QT prolongation 1

If Antipsychotics Become Necessary

For severe psychotic symptoms with delusions and hallucinations 4, 1:

• Risperidone: 0.25 mg at bedtime, maximum 2-3 mg/day 4

  • Extrapyramidal symptoms may occur at 2 mg/day 4
  • First-line atypical antipsychotic for agitated dementia with delusions 5

• Quetiapine: 12.5 mg twice daily (or 25 mg in morning if once-daily dosing required), maximum 200 mg twice daily 4

  • More sedating, beware of transient orthostasis 4
  • Preferred in patients with Parkinson's disease 5

• Olanzapine: 2.5 mg at bedtime, maximum 10 mg/day 4

  • Generally well tolerated but patients over 75 years respond less well 1
  • Avoid in patients with diabetes, dyslipidemia, or obesity 5

Duration of Antipsychotic Treatment

• Use at the lowest effective dose for the shortest possible duration 1
• Evaluate ongoing need daily with in-person examination 1
• For agitated dementia, taper within 3-6 months to determine the lowest effective maintenance dose 5
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—avoid this pitfall 1

What NOT to Use

Avoid benzodiazepines for routine management 4, 1:

• Regular use leads to tolerance, addiction, depression, and cognitive impairment 4
• Paradoxical agitation occurs in about 10% of elderly patients 4
• Can worsen delirium incidence and duration 1

Avoid typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy 4, 1:

• 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 4, 1
• Associated with significant cholinergic, cardiovascular, and extrapyramidal side effects 4

Practical Implementation for Your Patient

Given your patient's presentation with paranoia, extreme anxiety, and confusion from dementia:

1. Start citalopram 10 mg every morning (or sertraline 25 mg every morning) 1
2. Ensure she's taking it consistently like she does with her blood pressure medication 1
3. Reassess in 4 weeks using objective measures 1
4. If inadequate response, increase dose gradually (citalopram to 20 mg, then 40 mg maximum; or sertraline to 50 mg, then up to 200 mg) 4, 1
5. If SSRIs fail after adequate trial, consider trazodone 25 mg in morning or divalproex sodium 125 mg twice daily (both morning doses if necessary) 4
6. Reserve antipsychotics only for severe, dangerous agitation that fails the above approaches 1

Common Pitfalls to Avoid

• Don't jump to antipsychotics first—they carry significant mortality risk and should be reserved for severe, dangerous symptoms 1
• Don't continue medications indefinitely—review need at every visit and taper if no longer indicated 1
• Don't underestimate pain and discomfort as causes of behavioral symptoms in patients who cannot verbally communicate 1, 2
• Don't use antipsychotics for mild symptoms—they are only for severe symptoms that are dangerous or cause significant distress 1
• Don't forget to monitor for side effects including falls, metabolic changes, and cognitive worsening 1