What is a better option for managing Behavioral and Psychological Symptoms of Dementia (BPSD) with screaming in an elderly patient?

Management of BPSD with Screaming

For screaming in dementia patients, SSRIs (citalopram 10 mg/day or sertraline 25-50 mg/day) are the preferred pharmacological option after non-pharmacological interventions have been systematically attempted, as they target chronic agitation without the mortality risks associated with antipsychotics. 1

Immediate Assessment: Identify Reversible Causes

Before any intervention, systematically investigate underlying medical triggers that commonly drive screaming and vocal disturbances in patients who cannot verbally communicate discomfort:

• Pain assessment and management is a major contributor to behavioral disturbances and must be addressed first 1
• Screen for urinary tract infections and pneumonia, as these are frequent precipitants of vocal agitation 1, 2
• Check for constipation, urinary retention, and dehydration 1, 2
• Review all medications for anticholinergic effects (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen agitation 1
• Address sensory impairments (hearing aids, glasses) that increase confusion and fear 1

First-Line: Non-Pharmacological Interventions

Non-pharmacological strategies must be implemented and documented as attempted before considering medications, except in emergency situations with imminent risk of harm 1, 2:

Environmental Modifications

• Ensure adequate lighting and reduce excessive noise to minimize overstimulation 1, 3
• Create a predictable daily routine with regular physical exercise, meals, and consistent bedtime 3
• Remove potential hazards and install safety features like grab bars 3
• Use orientation aids (calendars, clocks, color-coded labels) to reduce confusion 3

Communication Strategies

• Use calm tones, simple one-step commands, and gentle touch for reassurance rather than complex multi-step instructions 1, 2
• Allow adequate time for the patient to process information before expecting a response 1
• Avoid harsh tones, open-ended questions, and confrontational approaches as these escalate agitation 2

Activity-Based Interventions

• Implement tailored activities based on individual abilities (e.g., Montessori activities) to reduce agitation 1, 4, 5
• Use diversional interventions to redirect attention from distressing stimuli 4

Second-Line: Pharmacological Treatment

Medications should only be used when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have been thoroughly attempted and documented as insufficient 1:

Preferred Option: SSRIs for Chronic Vocal Agitation

SSRIs are first-line pharmacological treatment for chronic agitation including screaming:

• Citalopram: Start 10 mg/day, maximum 40 mg/day 1
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day 1
• SSRIs significantly reduce overall neuropsychiatric symptoms, agitation, and depression in dementia patients 1
• Well tolerated with less effect on metabolism of other medications 1

Alternative Option: Trazodone

If SSRIs fail or are not tolerated:

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

Reserve Antipsychotics for Severe, Dangerous Agitation Only

Antipsychotics should only be used when screaming is accompanied by severe agitation with imminent risk of harm and SSRIs have failed:

• Risperidone: 0.25 mg at bedtime, maximum 2-3 mg/day (extrapyramidal symptoms at >2 mg/day) 1
• Quetiapine: 12.5 mg twice daily, maximum 200 mg twice daily (more sedating, orthostatic hypotension risk) 1
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine 1

Critical Safety Discussion Required

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

• Increased mortality risk (1.6-1.7 times higher than placebo) 1
• Cardiovascular effects, cerebrovascular adverse reactions, QT prolongation, falls 1
• Expected benefits and treatment goals 1

Monitoring and Reassessment

• Use quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) to assess baseline severity and monitor treatment response 1
• Evaluate response within 4 weeks of initiating pharmacological treatment 1
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 1
• Monitor for side effects: extrapyramidal symptoms, falls, metabolic changes, QT prolongation, cognitive worsening 1
• Daily in-person examination to evaluate ongoing need when using antipsychotics 1

Critical Pitfalls to Avoid

• Do not use antipsychotics as first-line treatment for screaming without attempting SSRIs first 2
• Avoid benzodiazepines as they increase delirium incidence and duration, cause paradoxical agitation in 10% of elderly patients, and risk tolerance and addiction 1
• Do not continue antipsychotics indefinitely without regular reassessment at every visit 1
• Avoid typical antipsychotics (haloperidol) as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use 1
• Do not underestimate pain as a cause of screaming in patients who cannot verbally communicate discomfort 1
• Remember that psychotropics are unlikely to impact repetitive verbalizations if they are not driven by agitation, psychosis, or depression 1