What are the recommended medications for a patient with agitation, possibly due to dementia or a psychiatric disorder?

Agitation Medications: Evidence-Based Recommendations

Direct Answer

For agitation in dementia or psychiatric disorders, begin immediately with non-pharmacological interventions (environmental modifications, pain assessment, treating reversible causes), and reserve medications only for severe, dangerous agitation after behavioral approaches fail—using low-dose atypical antipsychotics (risperidone 0.25-0.5 mg) for acute severe agitation with psychotic features, or SSRIs (citalopram 10 mg or sertraline 25-50 mg) for chronic agitation without psychosis. 1, 2

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Step 1: Mandatory Non-Pharmacological Interventions First

All patients must receive systematic non-pharmacological interventions before any medication is considered. 1, 2

Identify and Treat Reversible Medical Causes

• Pain assessment and management is the highest priority—pain is often undertreated and manifests as agitation in patients who cannot verbally communicate discomfort 1, 2
• Check for and treat urinary tract infections, pneumonia, and other infections 2
• Address constipation, urinary retention, dehydration, and hypoxia 2
• Review all medications for anticholinergic effects (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen agitation and cognitive function 2
• Correct metabolic derangements and optimize glucose control in diabetic patients 2

Environmental and Communication Modifications

• Reduce noise and ensure adequate lighting 1, 2
• Use calm tones, simple one-step commands, and gentle touch for reassurance 2
• Allow adequate time for the patient to process information before expecting a response 2
• Establish structured daily routines and meaningful activities tailored to the person's interests and abilities 1
• Install safety equipment (grab bars, handrails) and remove hazardous items 2

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Step 2: When to Consider Pharmacological Treatment

Medications should ONLY be used when: 1, 2

• The patient is severely agitated, threatening substantial harm to self or others
• Symptoms are dangerous or causing significant distress
• Non-pharmacological interventions have been thoroughly attempted and documented as insufficient
• Emergency situations with imminent risk of harm

Do NOT use medications for: 2

• Mild agitation
• Unfriendliness, poor self-care, memory problems, inattention
• Repetitive verbalizations/questioning, rejection of care, shadowing, or wandering

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Step 3: Medication Selection Algorithm

For Chronic Agitation WITHOUT Psychotic Features

First-Line: SSRIs 1, 2

• Citalopram: Start 10 mg/day, maximum 40 mg/day 2
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day 2
• Well tolerated with less effect on metabolism of other medications 2
• SSRIs significantly reduce overall neuropsychiatric symptoms, agitation, and depression 2
• Evaluate response within 4 weeks using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) 1, 2

Second-Line: Trazodone 2

• Start 25 mg/day, maximum 200-400 mg/day in divided doses 2
• Use caution in patients with premature ventricular contractions due to orthostatic hypotension risk 2

For Severe Agitation WITH Psychotic Features or Aggression

First-Line: Atypical Antipsychotics 1, 2, 3

Risperidone (preferred): 2, 3

• Start 0.25 mg once daily at bedtime 2
• Target dose 0.5-1.25 mg daily, maximum 2-3 mg/day 2
• Atypical antipsychotics probably reduce agitation slightly (SMD -0.21,95% CI -0.30 to -0.12) 1, 3
• Risk of extrapyramidal symptoms at doses above 2 mg/day 2, 3

Olanzapine (alternative): 2

• Start 2.5 mg at bedtime, maximum 10 mg/day 2
• Generally well tolerated but less effective in patients over 75 years 2
• FDA warning: increased mortality in elderly patients with dementia-related psychosis 4

Quetiapine (second-line): 2, 5

• Start 12.5 mg twice daily, maximum 200 mg twice daily 2, 5
• More sedating with risk of transient orthostasis 2, 5

For Acute Severe Agitation Requiring Immediate Intervention

Haloperidol (typical antipsychotic): 2

• 0.5-1 mg orally, IM, or subcutaneously 2
• Maximum 5 mg daily in elderly patients 2
• Can be given every 2 hours as required 2
• Higher risk of extrapyramidal symptoms compared to atypical antipsychotics 2, 3

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Step 4: Critical Safety Discussion Required BEFORE Starting Any Antipsychotic

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 in elderly dementia patients 2
• Cardiovascular effects, cerebrovascular adverse reactions 2
• Risk of QT prolongation, dysrhythmias, sudden death, hypotension 2
• Falls risk, pneumonia, metabolic effects 2
• Expected benefits (modest at best: SMD -0.21) and treatment goals 1, 2
• Alternative non-pharmacological approaches 2
• Plans for ongoing monitoring and reassessment 2

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Step 5: Monitoring and Reassessment Protocol

Initial Monitoring

• Use quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) to assess baseline severity and treatment response 1, 2
• Evaluate response within 4 weeks of initiating treatment 1, 2
• Daily in-person examination to evaluate ongoing need for antipsychotics 2

Monitor for Adverse Effects

• Extrapyramidal symptoms (tremor, rigidity, bradykinesia) 2
• Falls, sedation, orthostatic hypotension 2
• Metabolic changes, QT prolongation 2
• Cognitive worsening 2

Discontinuation Criteria

• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 1, 2
• Even with positive response, periodically reassess the need for continued medication 1, 2
• If significant side effects develop, review risk/benefit balance and consider tapering or discontinuing 1, 2
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—avoid inadvertent chronic use 2

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Critical Medications to AVOID

Never Use as First-Line

• Typical antipsychotics (haloperidol, fluphenazine, thiothixene): 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 2
• Benzodiazepines: Increase delirium incidence and duration, cause paradoxical agitation in 10% of elderly patients, risk of tolerance, addiction, cognitive impairment, and respiratory depression 2, 3
  • Exception: alcohol or benzodiazepine withdrawal 2
• Anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine): Worsen agitation and cognitive function 2
• Cholinesterase inhibitors: Should not be newly prescribed to prevent or treat delirium or agitation—associated with increased mortality 2

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Common Pitfalls to Avoid

• Do not continue antipsychotics indefinitely—review need at every visit and taper if no longer indicated 2
• Do not use antipsychotics for mild agitation—reserve for severe, dangerous symptoms 2
• Do not skip non-pharmacological interventions unless in an emergency situation 2
• Do not use doses higher than recommended—geriatric patients require lower doses with more gradual titration 2
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine—consider alternative treatments 2