How to manage agitation in dementia without using antipsychotics?

Managing Agitation in Dementia Without Antipsychotics

Non-pharmacological interventions must be implemented first and systematically attempted before any medication is considered, with SSRIs (citalopram or sertraline) as the preferred pharmacological option if behavioral approaches fail after adequate trial. 1

Step 1: Identify and Treat Reversible Medical Causes

Before implementing any intervention, aggressively search for underlying medical triggers that commonly drive agitation in dementia patients who cannot verbally communicate discomfort:

• Pain assessment and management is the single most important factor, as untreated pain is a major contributor to behavioral disturbances 1, 2
• Infections: Check for urinary tract infections and pneumonia, which frequently trigger agitation 2, 3
• Metabolic issues: Address dehydration, constipation, urinary retention, and hypoxia 2
• Medication review: Identify and discontinue anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen agitation 2
• Sensory impairments: Correct hearing and vision problems that increase confusion and fear 2

Step 2: Implement Individualized Non-Pharmacological Interventions

The DICE (Describe, Investigate, Create, Evaluate) approach provides a systematic framework 1:

Environmental Modifications

• Ensure adequate lighting and reduce excessive noise 2, 3
• Install safety equipment (grab bars, bath mats, tub benches) 1
• Create predictable daily routines for meals, exercise, and bedtime 3
• Simplify the environment with clear labels and structured layouts 2

Communication Strategies

• Use calm tones and simple one-step commands instead of complex multi-step instructions 1, 2
• Avoid harsh tones, open-ended questioning, and screaming 1
• Allow adequate time for the patient to process information before expecting a response 2
• Use gentle touch for reassurance 2

Activity-Based Interventions

• Music therapy is the most effective non-pharmacological intervention for reducing agitation, followed by aromatherapy/massage, then physical exercise 4
• Provide structured activities tailored to current capabilities and previous interests 3
• Use simulated presence therapy with audio/video recordings from family members 3
• Implement the "three R's" approach: repeat instructions, reassure the patient, redirect attention 3

Evidence for Non-Pharmacological Efficacy

A large randomized controlled trial demonstrated that individualized interventions addressing unmet needs (using the TREA methodology) produced statistically significant declines in total agitation (p<0.001), physical nonaggressive agitation (p<0.001), and verbal agitation (p=0.004), with significant increases in pleasure and interest 5. Sensory interventions specifically showed strong efficacy (SMD -1.07; 95% CI -1.76 to -0.38, p=0.002) 6.

Step 3: When Pharmacological Treatment Becomes Necessary

Medications should only be used when 1:

• The patient is severely agitated or distressed
• Threatening substantial harm to self or others
• Behavioral interventions have been systematically attempted and documented as insufficient
• Exception: Major depression with suicidal ideation requires immediate SSRI treatment 1

First-Line Pharmacological Option: SSRIs

Citalopram or sertraline are the preferred medications for chronic agitation without psychotic features 2, 3:

Citalopram:

• Start: 10 mg/day
• Maximum: 40 mg/day
• Well-tolerated; some patients experience nausea and sleep disturbances 2

Sertraline:

• Start: 25-50 mg/day
• Maximum: 200 mg/day
• Well-tolerated with less effect on metabolism of other medications 2

SSRIs significantly reduce overall neuropsychiatric symptoms, agitation, and depression in patients with vascular cognitive impairment and dementia 2, 3.

Second-Line Option: Trazodone

If SSRIs fail or are not tolerated 2:

• Start: 25 mg/day
• Maximum: 200-400 mg/day in divided doses
• Caution: Use carefully in patients with premature ventricular contractions due to orthostatic hypotension risk 2
• Safer alternative to antipsychotics with better tolerability profile 2

Step 4: Monitoring and Reassessment

Quantitative Assessment

Use standardized measures to establish baseline and monitor response 2, 3:

• Cohen-Mansfield Agitation Inventory (CMAI)
• Neuropsychiatric Inventory Questionnaire (NPI-Q)

Timeline for Evaluation

• Assess response within 4 weeks of initiating pharmacological treatment 1, 2
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 1, 3
• Even with positive response, periodically reassess the need for continued medication 3

Monitor for Side Effects

When using SSRIs, watch for 3:

• Sweating, tremors, nervousness
• Insomnia or somnolence
• Dizziness
• Gastrointestinal disturbances

What NOT to Use

Avoid these medications as they are ineffective or harmful 2:

• Benzodiazepines: Increase delirium incidence and duration, cause paradoxical agitation in 10% of elderly patients, risk of tolerance and addiction 2
• Typical antipsychotics (haloperidol as routine treatment): 50% risk of tardive dyskinesia after 2 years of continuous use 2
• Anticholinergic medications: Worsen agitation and cognitive function 2

Behaviors Unlikely to Respond to Medication

Psychotropics are not likely to impact the following symptoms, which require behavioral approaches only 1:

• Unfriendliness
• Poor self-care
• Memory problems
• Inattention
• Repetitive verbalizations/questioning
• Rejection or refusal of care
• Shadowing
• Wandering

Critical Caregiver Education

Educate caregivers that 1, 2:

• Behaviors are symptoms of dementia, not intentional actions
• Establishing a "new normal" routine promotes patient safety and well-being
• Question whether tasks must be done (e.g., can care be provided in bed instead of forcing transfers?)
• Time care activities when the patient is most calm and receptive

Common Pitfalls to Avoid

• Never use antipsychotics as first-line treatment for behavioral symptoms in dementia 2
• Do not skip the systematic investigation of reversible medical causes before implementing interventions 2, 3
• Avoid continuing medications indefinitely without regular reassessment and attempts at tapering 2
• Do not use medications for mild agitation that can be managed with behavioral approaches 1