What SSRI (selective serotonin reuptake inhibitor) can be added to a geriatric patient with dementia, likely of the Alzheimer's type, who is experiencing anxiety and exit-seeking behaviors and is already on mirtazapine, memantine, and donepezil?

SSRI Selection for Anxiety and Exit-Seeking in Geriatric Dementia

Add sertraline 25-50 mg daily or citalopram 10 mg daily as first-line pharmacological treatment for anxiety and exit-seeking behaviors in this patient already on mirtazapine, memantine, and donepezil. 1

Why SSRIs Are the Preferred Choice

The American Psychiatric Association explicitly recommends initiating SSRIs at low dose and titrating to minimum effective dose for chronic agitation in dementia, rather than adding benzodiazepines or antipsychotics. 1 This recommendation is particularly important because:

• SSRIs significantly reduce overall neuropsychiatric symptoms, agitation, and depression in patients with vascular cognitive impairment and dementia 1
• Benzodiazepines are sedating, cognitively impairing, cause unsafe mobility with injurious falls, and lead to habituation and withdrawal syndromes 2
• Antipsychotics worsen cognitive function in dementia and carry a black box FDA warning regarding risk of death 2

Specific SSRI Recommendations

First-Line Options

Sertraline (Zoloft):

• Start at 25-50 mg/day, maximum 200 mg/day 1
• Well tolerated with less effect on metabolism of other medications 1
• Particularly beneficial for chronic agitation without psychotic features 1

Citalopram (Celexa):

• Start at 10 mg/day, maximum 40 mg/day 1
• Well tolerated though some patients experience nausea and sleep disturbances 1
• Equally effective alternative to sertraline 1

Critical Prerequisites Before Adding SSRI

Before initiating any SSRI, systematically evaluate for delirium triggers as recommended by the American Medical Association: 2

• Pain assessment and management - major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort 1
• Infection screening - particularly urinary tract infections and pneumonia 1
• Metabolic disturbances - dehydration, electrolyte abnormalities, hypoxia 1
• Constipation and urinary retention - both significantly contribute to restlessness 1
• Medication review - identify anticholinergic medications that worsen agitation 1

Optimize Existing Regimen First

The American Geriatrics Society recommends optimizing existing regimens with memantine and donepezil before adding new medications. 2 Your patient's current regimen already includes:

• Memantine - demonstrates specific benefits for agitation and behavioral symptoms, with less agitation reported in treatment groups compared to placebo 2
• Donepezil + memantine combination - produces significant improvements in neuropsychiatric symptoms and reduced caregiver distress, particularly at 12 weeks 2

Allow adequate time for response - the combination therapy shows particular benefit for behavioral symptoms at 12 weeks, so ensure the patient has been on stable doses for at least this duration before adding an SSRI. 2

Treatment Timeline and Monitoring

• Assess response with quantitative measures (such as Cohen-Mansfield Agitation Inventory or NPI-Q) at baseline 1
• Evaluate response within 4 weeks of initiating SSRI at adequate dosing 1
• Taper and withdraw if no clinically significant response after 4 weeks at adequate dose 1
• Even with positive response, periodically reassess the need for continued medication 1

Non-Pharmacological Interventions Must Be Concurrent

Implement redirection techniques and environmental modifications as recommended by the Beers Criteria: 2

• Address caregiver stress and environmental stressors contributing to exit-seeking behaviors 2
• Use calm tones, simple one-step commands, and gentle touch for reassurance 1
• Ensure adequate lighting and reduce excessive noise 1
• Establish predictable daily routines to reduce confusion and anxiety 1

What NOT to Do

• Avoid benzodiazepines - risk of tolerance, addiction, cognitive impairment, and paradoxical agitation in 10% of elderly patients 1
• Avoid antipsychotics unless severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed 1
• Do not add multiple medications simultaneously without first addressing reversible causes 1

Mirtazapine Consideration

Your patient is already on mirtazapine, which has some anxiolytic properties. However, SSRIs have superior evidence specifically for agitation and behavioral symptoms in dementia compared to mirtazapine. 1 The combination of mirtazapine with an SSRI requires monitoring for serotonin syndrome, though this risk is relatively low at therapeutic doses.