What is the recommended treatment approach for mood swings in geriatric patients with dementia?

Treatment of Mood Swings in Dementia

Begin with non-pharmacological interventions as first-line treatment for mood swings in dementia, and only consider SSRIs (citalopram 10 mg/day or sertraline 25-50 mg/day) after behavioral approaches have been systematically attempted for at least 4 weeks and documented as insufficient, reserving antipsychotics exclusively for severe, dangerous agitation that poses imminent risk of harm. 1, 2

Step 1: Systematic Investigation of Underlying Medical Causes

Before any treatment, aggressively search for reversible medical triggers that commonly drive mood disturbances in dementia patients who cannot verbally communicate discomfort 1, 2:

• Pain assessment and management is a major contributor to behavioral disturbances and must be addressed first 1, 2
• Screen for infections: urinary tract infections, pneumonia, and other systemic infections 1, 2
• Check for metabolic disturbances: dehydration, constipation, urinary retention, hypoxia 1, 2
• Review all medications to identify and discontinue anticholinergic agents (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 1, 2
• Address sensory impairments: hearing or vision problems that increase confusion and fear 1, 2

Step 2: Intensive Non-Pharmacological Interventions (First-Line)

The American Academy of Neurology and American Geriatrics Society mandate attempting these interventions first and documenting them as failed before considering medications 1, 2:

Environmental Modifications

• Establish structured daily routines with predictable activities, regular physical exercise, consistent meal times, and fixed bedtimes 2
• Optimize lighting: ensure adequate bright light exposure during daytime (2 hours in the morning at 3,000-5,000 lux) to regulate circadian rhythms 2
• Reduce nighttime stimuli: minimize light and noise to create favorable sleep environments 2
• Remove hazards and install safety features: eliminate mirrors or reflective surfaces that can trigger hallucinations 2
• Use orientation aids: calendars, clocks, and color-coded labels for navigation 2

Communication Strategies

• Use calm tones, simple single-step commands, and gentle touch for reassurance 1, 2
• Apply the "three R's" approach: repeat instructions, reassure the patient, and redirect attention away from anxiety-provoking situations 2
• Avoid harsh tones, complex multi-step commands, open-ended questions, and confrontational approaches 2
• Allow adequate time for the patient to process information before expecting a response 1, 2

Caregiver Education

• Educate caregivers that behaviors are disease symptoms, not intentional actions, to reduce anxiety and promote empathy 1, 2
• Provide training in problem-solving techniques and supported conversation methods 2

Step 3: Pharmacological Treatment (Second-Line Only)

Medications should only be considered when 1, 2:

• Non-pharmacological approaches have been ineffective after adequate trial (at least 4 weeks)
• Behaviors pose significant safety risks
• The patient experiences severe distress from symptoms

First-Line Pharmacological: SSRIs

For chronic mood swings and agitation without psychotic features, the American Psychiatric Association and American Academy of Family Physicians recommend SSRIs as the preferred pharmacological option 1:

• Citalopram: Start 10 mg/day, maximum 40 mg/day 1
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day 1

SSRIs are particularly effective in vascular dementia, significantly improving overall neuropsychiatric symptoms, agitation, and depression 1. The Canadian Stroke Best Practice Recommendations explicitly designate SSRIs as first-line pharmacological treatment for agitation in vascular dementia 1.

Monitoring SSRI Response

• Assess response using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) within 4 weeks of adequate dosing 1
• If no clinically significant response after 4 weeks, taper and withdraw the medication 1
• Even with positive response, periodically reassess the need for continued medication 1

Alternative Option: Trazodone

If SSRIs fail or are not tolerated 1:

• Trazodone: Start 25 mg/day, maximum 200-400 mg/day in divided doses
• Use caution in patients with premature ventricular contractions due to risk of orthostatic hypotension (30% falls risk in real-world studies) 1

Reserved for Severe, Dangerous Agitation Only: Antipsychotics

Antipsychotics should ONLY be used when 1, 2:

• The patient is severely agitated or distressed
• Threatening substantial harm to self or others
• Behavioral interventions have failed or are not possible
• SSRIs have been tried for adequate duration without response

Before initiating antipsychotics, the American Psychiatric Association requires discussing with the patient (if feasible) and surrogate decision maker 1:

• Increased mortality risk (1.6-1.7 times higher than placebo)
• Cardiovascular effects and cerebrovascular adverse reactions
• Risk of QT prolongation, dysrhythmias, sudden death, hypotension, pneumonia, falls
• Metabolic effects and extrapyramidal symptoms

If antipsychotics are necessary 1:

• Risperidone: Start 0.25 mg at bedtime, maximum 2-3 mg/day (extrapyramidal symptoms at ≥2 mg/day)
• Quetiapine: Start 12.5 mg twice daily, maximum 200 mg twice daily (more sedating, risk of orthostasis)
• Use lowest effective dose for shortest possible duration with daily in-person examination 1
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine 1

Critical Pitfalls to Avoid

• Never continue antipsychotics indefinitely: Review need at every visit and taper if no longer indicated 1
• Never use antipsychotics for mild mood swings: Reserve them for severe symptoms that are dangerous or cause significant distress 1
• Never skip non-pharmacological interventions unless in an emergency situation 1, 2
• Never use benzodiazepines routinely: They increase delirium incidence and duration, cause paradoxical agitation in 10% of elderly patients, and risk tolerance, addiction, and cognitive impairment 1
• Avoid typical antipsychotics (haloperidol) as first-line due to 50% risk of tardive dyskinesia after 2 years of continuous use 1
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication: Inadvertent chronic use must be avoided 1