What medication is recommended for dementia agitation?

Medication for Dementia Agitation

For chronic agitation in dementia, initiate an SSRI (citalopram 10 mg/day or sertraline 25-50 mg/day) as first-line pharmacological treatment after non-pharmacological interventions have been attempted; reserve low-dose atypical antipsychotics (risperidone 0.25-1 mg/day) only for severe, dangerous agitation with psychotic features when behavioral approaches have failed. 1

Treatment Algorithm

Step 1: Non-Pharmacological Interventions (Always First)

• Identify and treat reversible causes including pain (often undertreated and manifests as agitation), urinary tract infections, constipation, dehydration, and medication side effects—particularly anticholinergic medications that worsen agitation 1, 2
• Implement environmental modifications: adequate lighting, reduced noise, structured daily routines, and meaningful activities tailored to the patient's interests 1, 2
• Use calm tones, simple one-step commands, gentle touch for reassurance, and allow adequate time for the patient to process information 1
• Document these interventions as attempted and insufficient before proceeding to medications 1, 2

Step 2: First-Line Pharmacological Treatment (Chronic Agitation)

SSRIs are the preferred initial medication for mild-to-moderate chronic agitation without psychotic features: 1

• Citalopram: Start 10 mg/day, maximum 40 mg/day; well-tolerated though some patients experience nausea and sleep disturbances 3, 1
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day; well-tolerated with less effect on metabolism of other medications 3, 1

Critical monitoring: Assess response using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) within 4 weeks of adequate dosing 1, 2. If no clinically significant response after 4 weeks, taper and withdraw the medication 1, 2.

Step 3: Second-Line Options (If SSRIs Fail or Not Tolerated)

Trazodone may be considered: Start 25 mg/day, maximum 200-400 mg/day in divided doses 3, 1. Use with caution in patients with premature ventricular contractions due to risk of orthostatic hypotension 3, 1.

Step 4: Atypical Antipsychotics (Severe Agitation with Psychotic Features)

Reserve for patients who are severely agitated, threatening substantial harm to self or others, with psychotic features (delusions, hallucinations), and only after behavioral interventions have failed. 1, 4, 2

Before initiating, you must discuss with the patient (if feasible) and surrogate decision-maker: 1, 2

• Increased mortality risk (1.6-1.7 times higher than placebo) 1, 5
• Cardiovascular effects including QT prolongation, dysrhythmias, sudden death 1
• Risk of falls, pneumonia, metabolic changes, and extrapyramidal symptoms 1

Medication selection for severe agitation with psychotic features:

• Risperidone (first-line atypical): Start 0.25 mg at bedtime, increase by 0.25 mg increments every 5-7 days; target dose 0.5-1.25 mg/day, maximum 2 mg/day 3, 4, 6, 7. Extrapyramidal symptoms may occur at doses ≥2 mg/day 3, 4. Moderate-certainty evidence shows risperidone probably reduces agitation slightly (SMD -0.21) 4, 2.

• Olanzapine (alternative): Start 2.5 mg at bedtime, maximum 10 mg/day in divided doses; generally well-tolerated but patients over 75 years respond less well 3, 1

• Quetiapine (alternative): Start 12.5 mg twice daily, maximum 200 mg twice daily; more sedating with risk of transient orthostasis 3, 1

Duration and monitoring: Use the lowest effective dose for the shortest possible duration with daily in-person examination 1. Evaluate response within 4 weeks; if no benefit, taper and discontinue 1, 2. Monitor for extrapyramidal symptoms, falls, metabolic changes, and cognitive worsening 1.

Step 5: Acute Severe Agitation (Emergency Situations)

For acute, dangerous agitation with imminent risk of harm when immediate intervention is required:

• Haloperidol: 0.5-1 mg orally or subcutaneously, maximum 5 mg daily in elderly patients 1. This is reserved only for emergency situations when the patient poses imminent danger 1.

Critical Warnings and Pitfalls

What NOT to Use

• Avoid typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 3, 1
• Avoid benzodiazepines for routine agitation management due to risk of tolerance, addiction, cognitive impairment, increased delirium incidence and duration, and paradoxical agitation in 10% of elderly patients 3, 1
• Avoid anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) as they worsen agitation and cognitive function 1

Common Pitfalls

• Never continue antipsychotics indefinitely without reassessment—approximately 47% of patients continue receiving antipsychotics after discharge without clear indication 1. Review need at every visit and taper if no longer indicated 1.
• Do not use antipsychotics for mild agitation—they are reserved only for severe, dangerous symptoms 1, 2
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine, and short-term treatment is associated with increased mortality 1
• The benefits of antipsychotics are at best small in clinical trials (modest effect sizes), so the risk-benefit calculation must be carefully considered 2

Reassessment Strategy

Even with positive response to any medication, periodically reassess the need for continued treatment 1, 2. For antipsychotics specifically, attempt tapering within 3-6 months to determine the lowest effective maintenance dose 1.