What medication should be tried next for an elderly patient with dementia and disruptive behavior who is not responding to Risperdal (risperidone)?

Alternative Medication for Elderly Patient with Dementia and Worsening Disruptive Behavior on Risperidone

Switch to an SSRI, specifically citalopram 10 mg/day or sertraline 25-50 mg/day, as these are the guideline-recommended first-line pharmacological treatments for chronic agitation in dementia, with risperidone reserved only for severe agitation with psychotic features or imminent risk of harm. 1

Why Risperidone May Be Making Things Worse

• Risperidone can cause extrapyramidal symptoms even at low doses in elderly patients with dementia, which may paradoxically worsen agitation and behavioral disturbances 2
• The American Academy of Family Physicians notes that extrapyramidal symptoms (tremor, rigidity, bradykinesia) occur at doses above 2 mg/day, but can develop even with doses as low as 0.5 mg/day in some elderly patients 1, 2
• Cognitive decline can occur with risperidone treatment, which may manifest as increased confusion and worsening behavioral symptoms 2

Recommended Next Step: Switch to SSRI

The American Psychiatric Association recommends initiating SSRIs at low dose and titrating to minimum effective dose for chronic agitation in dementia. 1

Specific SSRI Options:

Citalopram:

• Start at 10 mg/day, maximum 40 mg/day 1
• Well tolerated, though some patients experience nausea and sleep disturbances 1
• Assess response using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) after 4 weeks of adequate dosing 1

Sertraline:

• Start at 25-50 mg/day, maximum 200 mg/day 1
• Well tolerated with less effect on metabolism of other medications 1
• Significantly reduces overall neuropsychiatric symptoms, agitation, and depression in patients with vascular cognitive impairment and dementia 1

Critical Actions Before Medication Change

Before switching medications, systematically investigate underlying causes that may be driving the worsening behavior: 1

• Pain assessment: Untreated pain is a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort 1
• Infections: Check for urinary tract infections and pneumonia, which are major triggers of behavioral symptoms 1
• Constipation and urinary retention: These commonly worsen agitation in elderly patients 1
• Medication review: Identify anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen agitation and cognitive function 1
• Metabolic disturbances: Address dehydration, hypoxia, and electrolyte imbalances 1

Treatment Algorithm

Step 1: Address Reversible Causes (24-48 hours)

• Treat pain, infections, constipation, urinary retention 1
• Remove or reduce anticholinergic medications 1
• Optimize environmental factors (adequate lighting, reduce noise, structured routine) 1

Step 2: Taper Risperidone While Starting SSRI

• Begin citalopram 10 mg/day or sertraline 25-50 mg/day 1
• Gradually taper risperidone over 1-2 weeks to avoid withdrawal symptoms 1
• SSRIs require 4 weeks at adequate dose to assess response 1

Step 3: Monitor and Reassess (4 weeks)

• Use quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) to objectively track response 1
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the SSRI 1
• Consider alternative: trazodone 25 mg/day (maximum 200-400 mg/day in divided doses) 1

Alternative Second-Line Options If SSRIs Fail

Trazodone:

• Start 25 mg/day, maximum 200-400 mg/day in divided doses 1
• Safer alternative to antipsychotics with better tolerability profile 1
• Use caution in patients with premature ventricular contractions due to risk of orthostatic hypotension 1

Quetiapine (if antipsychotic still needed):

• Start 12.5 mg twice daily, maximum 200 mg twice daily 1
• More sedating than risperidone, with risk of orthostatic hypotension 1
• May be better tolerated than risperidone in terms of extrapyramidal symptoms 3

When to Consider Returning to Antipsychotics

Antipsychotics should only be used when: 1

• The patient is severely agitated, threatening substantial harm to self or others 1
• Behavioral interventions have been thoroughly attempted and documented as insufficient 1
• There are psychotic features (hallucinations, delusions) driving the aggression 1

If antipsychotic is absolutely necessary:

• Use the lowest effective dose for the shortest possible duration 1
• Evaluate ongoing need daily with in-person examination 1
• Discuss increased mortality risk (1.6-1.7 times higher than placebo) with surrogate decision maker 1

Critical Safety Warnings

• All antipsychotics increase mortality risk in elderly patients with dementia 1
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine 1
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—inadvertent chronic use should be avoided 1
• Even with positive response to SSRIs, periodically reassess the need for continued medication 1

Common Pitfalls to Avoid

• Do not continue risperidone indefinitely without reassessing whether the behavior truly requires antipsychotic treatment 1
• Do not add benzodiazepines as they can cause paradoxical agitation in 10% of elderly patients and worsen cognitive function 1
• Do not use typical antipsychotics (haloperidol, fluphenazine) as first-line due to 50% risk of tardive dyskinesia after 2 years of continuous use 1
• Do not skip the investigation of reversible causes—medical triggers are often the primary driver of worsening behavior 1