What medications are recommended for an elderly patient with dementia and psych disturbance?

Pharmacological Management of Dementia with Psychiatric Disturbance

For elderly patients with dementia and psychiatric disturbances, SSRIs (specifically citalopram 10-40 mg/day or sertraline 25-200 mg/day) are the first-line pharmacological treatment for chronic agitation, while low-dose atypical antipsychotics (risperidone 0.25-1.25 mg/day) should be reserved only for severe, dangerous agitation with psychotic features after non-pharmacological interventions have failed. 1, 2

Step 1: Mandatory Assessment Before Any Medication

Before initiating any psychotropic medication, you must systematically investigate and treat reversible medical triggers:

• Pain assessment and management is the single most important intervention, as untreated pain is a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort 1, 2
• Rule out infections, particularly urinary tract infections and pneumonia, which commonly drive psychiatric symptoms in dementia 1, 2
• Check for metabolic derangements including dehydration, electrolyte abnormalities, hypoxia, and hyperglycemia 1, 2
• Evaluate for constipation and urinary retention, both of which significantly worsen agitation 1, 2
• Review all medications to identify and discontinue anticholinergic agents (diphenhydramine, oxybutynin, cyclobenzaprine, hydroxyzine) that worsen confusion and agitation 3, 1
• Address sensory impairments including hearing and vision problems that increase confusion and fear 1, 2

Step 2: Non-Pharmacological Interventions (Must Be Attempted First)

Non-pharmacological interventions have substantial evidence for efficacy without the mortality risks of medications and must be systematically attempted and documented as failed before prescribing psychotropics 1, 2, 4:

Environmental Modifications

• Ensure adequate lighting and reduce excessive noise to prevent agitation 1, 2
• Install safety equipment including door alarms, coded locks, grab bars, and register patient in Alzheimer's Association Safe Return Program 1
• Simplify the environment with clear labels, structured layouts, and removal of mirrors that may cause distress 1
• Establish predictable daily routines for meals, exercise, and toileting at consistent times 1

Communication Strategies

• Use calm tones and simple one-step commands instead of complex multi-step instructions 1, 2
• Allow adequate time for the patient to process information before expecting a response 1, 2
• Employ the "three R's" approach: repeat instructions, reassure the patient, and redirect attention 2

Activity-Based Interventions

• Provide meaningful activities tailored to the patient's interests and cognitive level to reduce boredom-driven wandering 1
• Use ABC charting (antecedent-behavior-consequence) to identify specific triggers of behavioral symptoms 1, 2

Step 3: First-Line Pharmacological Treatment - SSRIs

When non-pharmacological interventions are insufficient after 24-48 hours and symptoms are causing significant distress, initiate an SSRI as first-line pharmacological treatment 1, 2, 4:

Preferred SSRI Options

Citalopram:

• Start at 10 mg/day, maximum 40 mg/day 2, 4
• Well tolerated, though some patients experience nausea and sleep disturbances 2
• Significantly reduces overall neuropsychiatric symptoms, agitation, and depression in vascular cognitive impairment and dementia 2, 4

Sertraline:

• Start at 25-50 mg/day, maximum 200 mg/day 1, 2, 4
• Well tolerated with less effect on metabolism of other medications 2, 4
• Preferred when drug-drug interactions are a concern 4

SSRI Monitoring and Duration

• Evaluate response within 4 weeks using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) 1, 2, 4
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 2, 4
• Even with positive response, periodically reassess the need for continued medication 4
• Consider tapering after 9 months to reassess necessity 4

Step 4: Second-Line Treatment - Atypical Antipsychotics

Atypical antipsychotics should ONLY be used when:

• The patient is severely agitated, threatening substantial harm to self or others 1, 2, 4
• Behavioral interventions have been thoroughly attempted and documented as insufficient 1, 2, 4
• Symptoms include severe agitation with psychotic features (delusions, hallucinations) or dangerous aggression 1, 2, 4
• Emergency situations with imminent risk of harm 2, 4

Critical Safety Discussion Required

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

• Increased mortality risk (1.6-1.7 times higher than placebo) in elderly dementia patients 2, 4
• Cardiovascular effects including QT prolongation, dysrhythmias, and sudden death 2, 4
• Cerebrovascular adverse reactions including three-fold increase in stroke risk with risperidone and olanzapine 4
• Expected benefits and treatment goals, which are at best small in clinical trials 2, 4
• Alternative non-pharmacological approaches and plans for ongoing monitoring 4

Preferred Atypical Antipsychotic - Risperidone

Risperidone is the preferred atypical antipsychotic based on moderate-certainty evidence showing it probably reduces agitation slightly (SMD -0.21) 1:

• Start at 0.25 mg once daily at bedtime 1, 2, 4
• Titrate by 0.25 mg increments every 5-7 days as tolerated 1
• Target dose: 0.5-1.25 mg daily, maximum 2 mg/day 1, 2, 4
• Extrapyramidal symptoms increase significantly at doses above 2 mg/day 4

Alternative Atypical Antipsychotics

Quetiapine:

• Start at 12.5 mg twice daily, maximum 200 mg twice daily 2, 4
• More sedating with higher risk of orthostatic hypotension 2, 4
• Consider when extrapyramidal symptoms are a particular concern 5

Olanzapine:

• Start at 2.5 mg at bedtime, maximum 10 mg/day in divided doses 2, 4
• Generally well tolerated but less effective in patients over 75 years 4
• Risk of oversedation and metabolic effects 4

Antipsychotic Monitoring and Duration

Use the lowest effective dose for the shortest possible duration 1, 2, 4:

• Daily in-person examination to evaluate ongoing need 2, 4
• Monitor for extrapyramidal symptoms (tremor, rigidity, bradykinesia) 2, 4
• Monitor for falls risk, orthostatic hypotension, and sedation 1, 2, 4
• Monitor for metabolic changes including weight gain and glucose dysregulation 2, 4
• ECG monitoring for QT prolongation 2, 4
• Evaluate response within 4 weeks using quantitative measures 2, 4
• Taper and discontinue if no clinically meaningful benefit after adequate trial 2, 4
• Review need at every visit and taper if no longer indicated 4

Step 5: Acute Emergency Management

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

Haloperidol 0.5-1 mg orally or subcutaneously is the first-line medication for acute agitation 4:

• Maximum 5 mg daily in elderly patients 4
• Provides targeted treatment with lower risk of respiratory depression compared to benzodiazepines 4
• Monitor for extrapyramidal symptoms and QT prolongation 4
• Use only for shortest duration possible with daily reassessment 4

Critical Medications to AVOID

Benzodiazepines

Avoid benzodiazepines as first-line treatment except in alcohol or benzodiazepine withdrawal 4:

• Increase delirium incidence and duration 4
• Cause paradoxical agitation in approximately 10% of elderly patients 4
• Risk of tolerance, addiction, cognitive impairment, and respiratory depression 4

Typical Antipsychotics

Avoid typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy for chronic management 4:

• 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 4
• Reserve haloperidol only for acute emergency situations 4

Anticholinergic Medications

Minimize or discontinue all anticholinergic medications 3, 1:

• Diphenhydramine, hydroxyzine, oxybutynin, cyclobenzaprine worsen confusion and agitation 1
• Use alternative medications for specific indications (e.g., SSRIs for depression, gabapentin for neuropathic pain) 3

Cholinesterase Inhibitors

Do not newly prescribe cholinesterase inhibitors to prevent or treat delirium or agitation 4:

• Associated with increased mortality in this context 4

Common Pitfalls to Avoid

• Never continue antipsychotics indefinitely - approximately 47% of patients continue receiving antipsychotics after discharge without clear indication 4
• Do not use antipsychotics for mild agitation - reserve for severe, dangerous symptoms only 4
• Do not skip non-pharmacological interventions unless in an emergency situation 1, 2, 4
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine - consider this when selecting agents 4
• Do not use psychotropics for behaviors unlikely to respond: unfriendliness, poor self-care, memory problems, inattention, repetitive verbalizations/questioning, rejection of care, shadowing, or wandering 4