What pharmacological recommendations are suitable for an elderly female resident in a long-term care facility with dementia and behavioral disturbances, presenting with verbal and physical aggression, who is currently taking citalopram (Selective Serotonin Reuptake Inhibitor - SSRI) 40 milligrams daily and buspirone (anxiolytic) 7.5 milligrams twice daily, and for whom antipsychotics are contraindicated?

Pharmacological Recommendations for Dementia with Aggressive Behaviors When Antipsychotics Are Contraindicated

Given that antipsychotics are contraindicated, optimize the current citalopram dose to 40 mg daily (already at maximum), consider adding divalproex sodium 125 mg twice daily titrated to therapeutic levels for severe agitation, or add trazodone 25 mg daily with gradual titration up to 200-400 mg daily in divided doses as alternative mood-stabilizing options. 1

Current Medication Assessment

Your resident is already on:

• Citalopram 40 mg daily - This is at the FDA maximum dose for elderly patients and represents appropriate first-line SSRI therapy 2
• Buspirone 7.5 mg twice daily - This is a relatively low dose; buspirone can be effective for behavioral disturbances in dementia at mean doses of 25.7 mg daily, though it requires 2-4 weeks to become fully effective 3, 1

The citalopram is appropriately dosed as SSRIs are the preferred first-line pharmacological treatment for chronic agitation in dementia 1. However, at 40 mg daily (the maximum recommended dose for elderly patients), there is limited room for further optimization 2.

Critical First Step: Rule Out Reversible Medical Causes

Before adding any medications, systematically investigate and treat:

• Pain assessment and management - This is a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort 1
• Infections - Check for urinary tract infections and pneumonia, which are disproportionately common contributors to neuropsychiatric symptoms 1
• Constipation and urinary retention - Both significantly contribute to restlessness and aggression 1
• Metabolic disturbances - Evaluate for dehydration, electrolyte abnormalities, and hypoxia 1
• Medication review - Identify and discontinue anticholinergic medications (diphenhydramine, hydroxyzine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 1

Pharmacological Options When Antipsychotics Cannot Be Used

Option 1: Optimize Buspirone Dosing

Increase buspirone gradually to a target dose of 25-30 mg daily in divided doses (e.g., 15 mg twice daily). 3

• A retrospective study of 179 patients showed 68.6% responded to buspirone for behavioral disturbances in dementia, with mean effective dose of 25.7 mg daily 3
• Buspirone demonstrated efficacy for both verbal aggression (69.8% of patients) and physical aggression (64.8% of patients) 3
• Important caveat: Buspirone requires 2-4 weeks to become fully effective, so this is not appropriate for acute, dangerous situations 1
• Buspirone has a favorable safety profile with minimal risk of sedation, falls, or cognitive impairment compared to other options 3

Option 2: Add Divalproex Sodium (Preferred for Severe Agitation Without Psychotic Features)

Start divalproex sodium 125 mg twice daily, titrating to therapeutic blood levels (50-100 mcg/mL). 1

• The American Academy of Family Physicians recommends divalproex sodium specifically for severe agitation without psychotic features in dementia 1
• This is particularly appropriate when antipsychotics are contraindicated, as it provides mood stabilization through a different mechanism 1
• Monitoring requirements: Check liver enzymes and coagulation parameters regularly 1
• Titrate gradually based on clinical response and blood levels 1

Option 3: Add Trazodone (Alternative Mood Stabilizer)

Start trazodone 25 mg daily at bedtime, with gradual titration up to 200-400 mg daily in divided doses. 1, 4

• Trazodone is specifically indicated for control of severe agitated, repetitive, and combative behaviors in dementia patients 4
• It has a better tolerability profile than antipsychotics with lower risk of extrapyramidal symptoms 1
• Critical safety concern: Use caution in patients with premature ventricular contractions or cardiac conditions due to risk of arrhythmias and orthostatic hypotension 1
• Falls risk is approximately 30% in real-world studies, so careful monitoring is essential 1
• Start low and titrate slowly over several weeks 1

Treatment Algorithm

Step 1: Ensure all reversible medical causes have been addressed (pain, infections, constipation, medication review) 1

Step 2: Optimize buspirone to 25-30 mg daily in divided doses over 2-3 weeks 3

Step 3: If inadequate response after 4 weeks at optimized buspirone dose, add either:

• Divalproex sodium 125 mg twice daily (preferred for severe, non-psychotic agitation) 1, OR
• Trazodone 25 mg daily (if cardiac risk is acceptable) 1, 4

Step 4: Reassess response using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) after 4 weeks of adequate dosing 1

Step 5: If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the added medication 1

Critical Safety Warnings

Serotonin syndrome risk: The combination of citalopram 40 mg with buspirone creates potential risk for serotonin syndrome, particularly if adding other serotonergic agents 2. Monitor for mental status changes, autonomic instability, neuromuscular symptoms, and gastrointestinal symptoms 2.

Avoid benzodiazepines: Do not use benzodiazepines (lorazepam, diazepam) for routine agitation management, as they increase delirium incidence and duration, cause paradoxical agitation in approximately 10% of elderly patients, and worsen cognitive function 1, 4

Medication duration: Even with positive response, periodically reassess the need for continued medication, with attempts at tapering within 3-6 months to determine if still needed 1

What NOT to Do

• Do not add typical antipsychotics (haloperidol, fluphenazine) - These carry 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 1
• Do not use benzodiazepines except for alcohol or benzodiazepine withdrawal 1
• Do not add multiple psychotropics simultaneously without first optimizing existing medications and treating reversible causes 1
• Do not use cholinesterase inhibitors for acute behavioral management - they have been associated with increased mortality when newly prescribed for agitation 1

Non-Pharmacological Interventions (Must Be Concurrent)

These must be implemented alongside any medication adjustments:

• Use calm tones, simple one-step commands, and gentle touch for reassurance 1
• Ensure adequate lighting and reduce excessive noise 1
• Provide structured daily routines and predictable schedules 4
• Use ABC (antecedent-behavior-consequence) charting to identify specific triggers 1
• Educate caregivers that behaviors are symptoms of dementia, not intentional actions 1
• Ensure adequate pain management before attempting care activities 1

Monitoring Plan

• Week 2: Assess for early side effects and medication tolerance 1
• Week 4: Formal reassessment using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) 1
• Ongoing: Monitor for falls, sedation, metabolic changes, and cognitive worsening 1
• Every 3-6 months: Attempt taper to determine if medication still needed 1