For an elderly patient with dementia, is starting buspirone 5mg twice a day and keeping alprazolam as needed a suitable approach for managing agitation and anxiety?

Buspirone and Alprazolam for Elderly Dementia Patient: Not the Right Move

This medication regimen is inappropriate and potentially harmful—buspirone has limited evidence for acute agitation in dementia, and continuing alprazolam (a benzodiazepine) directly contradicts guideline recommendations due to increased risks of falls, cognitive decline, delirium, and paradoxical agitation in elderly patients. 1

Why This Regimen Is Problematic

Alprazolam Should Be Discontinued, Not Continued

• Benzodiazepines like alprazolam should be avoided in elderly dementia patients because they increase delirium incidence and duration, cause paradoxical agitation in approximately 10% of elderly patients, and carry risks of tolerance, addiction, cognitive impairment, falls, and respiratory depression. 1

• The American Geriatrics Society explicitly recommends against using benzodiazepines as first-line treatment for agitated delirium or behavioral disturbances in dementia, with a maximum dose of 2 mg/day only in exceptional circumstances like alcohol withdrawal. 1, 2

• Continuing alprazolam PRN perpetuates these risks and undermines any potential benefit from adding buspirone. 2

Buspirone Has Weak Evidence for Acute Agitation

• While buspirone showed 68.6% response rates in a retrospective study of 179 dementia patients with behavioral disturbances (mean dose 25.7 mg), this was for chronic management, not acute crisis situations threatening facility discharge. 3

• Buspirone requires 2-4 weeks to achieve therapeutic effect for anxiety and agitation, making it unsuitable for the urgent situation described where the patient is at immediate risk of facility discharge. 4

• The evidence for buspirone consists primarily of small case series and retrospective reviews, not the high-quality randomized controlled trials that support other interventions. 4, 3

What Should Be Done Instead

Step 1: Immediate Assessment of Reversible Causes (Within 24 Hours)

• Systematically investigate medical triggers that commonly drive behavioral disturbances in dementia patients who cannot verbally communicate discomfort: pain, urinary tract infections, pneumonia, constipation, urinary retention, dehydration, and medication side effects (especially anticholinergic medications). 1

• Review all current medications to identify and discontinue anticholinergic agents (diphenhydramine, hydroxyzine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation. 1

• Check for sensory impairments (hearing, vision) that increase confusion and fear. 1

Step 2: Intensive Non-Pharmacological Interventions (Immediate Implementation)

• Environmental modifications: ensure adequate lighting, reduce excessive noise, provide structured daily routines, install safety equipment. 1

• Communication strategies: use calm tones, simple one-step commands, gentle touch for reassurance, allow adequate time for processing information. 1

• Document these interventions systematically using ABC (antecedent-behavior-consequence) charting to identify specific triggers and patterns. 1

Step 3: Appropriate Pharmacological Management

For chronic agitation without psychotic features (if behavioral interventions fail after 24-48 hours):

• First-line: SSRIs (citalopram 10 mg/day or sertraline 25-50 mg/day), which have the strongest evidence for reducing overall neuropsychiatric symptoms, agitation, and depression in dementia. 1

• Assess response within 4 weeks using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q); if no response, taper and discontinue. 1

For severe agitation with psychotic features or imminent risk of harm:

• Risperidone 0.25-0.5 mg at bedtime is first-line, with careful titration to 0.5-1.25 mg daily maximum. 1, 5, 6

• Alternative: quetiapine 12.5 mg twice daily (more sedating, risk of orthostatic hypotension). 1

• Critical safety discussion required: Before initiating any antipsychotic, discuss with the patient's surrogate decision maker the 1.6-1.7 times increased mortality risk, cardiovascular effects, cerebrovascular adverse reactions, falls, and metabolic changes. 1

• Use the lowest effective dose for the shortest possible duration with daily in-person reassessment. 1

Step 4: Deprescribe the Alprazolam

• Gradually taper alprazolam over 1-2 weeks to avoid withdrawal syndrome, reducing by 25% every 3-5 days. 2

• Monitor weekly for rebound anxiety, agitation, and withdrawal symptoms. 2

Critical Pitfalls to Avoid

• Do not use antipsychotics for mild agitation—they are reserved only for severe symptoms that are dangerous or cause significant distress after behavioral interventions have failed. 1

• Do not continue antipsychotics indefinitely—review need at every visit and attempt tapering within 3-6 months to determine the lowest effective maintenance dose. 1, 5

• Do not combine multiple sedating medications (benzodiazepines + antipsychotics + buspirone) as this dramatically increases risks of falls, respiratory depression, and excessive sedation. 2

• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—inadvertent chronic use must be avoided. 1

Bottom Line for This Case

The proposed regimen of buspirone 5 mg BID plus PRN alprazolam fails on multiple fronts: it continues a contraindicated benzodiazepine, adds a medication with insufficient evidence for acute agitation, and bypasses the guideline-recommended systematic approach of investigating reversible causes, implementing non-pharmacological interventions, and using SSRIs as first-line pharmacological treatment. 1, 2

Recommend instead: Discontinue alprazolam, aggressively search for and treat medical triggers (especially pain, UTI, constipation), implement intensive behavioral interventions with ABC charting, and if pharmacological treatment becomes necessary after 24-48 hours, initiate an SSRI (citalopram 10 mg/day or sertraline 25-50 mg/day) for chronic management, reserving low-dose risperidone (0.25-0.5 mg) only for severe, dangerous agitation with imminent risk of harm. 1