From the Guidelines
SSRIs are considered the first-line treatment for agitation in patients with vascular dementia, due to their ability to significantly reduce overall neuropsychiatric symptoms, agitation, and depression. When considering the management of neuropsychiatric symptoms in patients with vascular dementia, it is essential to prioritize non-pharmacological approaches, such as cognitive behavioral therapies (CBTs), physical activity, and simulated presence therapy (SPT), as they have been shown to improve mood, increase the odds of depression remission, and improve quality of life 1.
For patients with depression, treatment with serotonergic antidepressants, including SSRIs, has been found to significantly improve overall neuropsychiatric symptoms, agitation, and depression 1. In subgroup analysis, SSRIs as a class were found to significantly reduce overall neuropsychiatric symptoms, but non-SSRIs did not, while both drug classes reduced agitation 1.
Some key points to consider when managing neuropsychiatric symptoms in patients with vascular dementia include:
- Non-pharmacological approaches should always be tried first, including maintaining routine, providing appropriate stimulation, addressing underlying medical issues, and creating a calm environment.
- When medications are necessary, start with the lowest possible dose, monitor closely for side effects, and regularly reassess the need for continued treatment, aiming to taper and discontinue when possible.
- Typical and atypical antipsychotics can also reduce agitation and psychosis, but have been discouraged and should be used with caution due to increased risk of death, probably from cardiac toxicities 1.
- Massage therapy, animal-assisted interventions, personally tailored interventions, and even pet robot interventions have been shown to help agitation in individuals with severe dementia living in nursing homes 1.
Overall, the goal is to balance symptom management with minimizing medication-related risks in this vulnerable population, and SSRIs, such as sertraline or escitalopram, are often preferred for the treatment of depression and agitation in patients with vascular dementia.
From the Research
Medications for Neuropsychiatric Symptoms of Dementia
- Atypical antipsychotics, such as risperidone and aripiprazole, have been shown to be effective in treating aggression in people with Alzheimer's disease, but their use is limited due to significant adverse events 2, 3.
- Other pharmacological treatments, such as carbamazepine, memantine, and citalopram, have limited evidence to support their use 2.
- Selective serotonin reuptake inhibitors (SSRIs) have been investigated as an alternative treatment for neuropsychiatric symptoms, but more research is needed to determine their efficacy 4.
Non-Pharmacological Treatments
- Non-pharmacological treatments, such as social interaction and person-centred care training, have been shown to be effective in managing neuropsychiatric symptoms 2, 5.
- Behavioral and psychosocial interventions have been found to be effective, but their implementation in routine clinical practice can be challenging 4, 5.
Treatment Approach
- A multidisciplinary expert panel recommends a sequential and iterative approach to managing neuropsychiatric symptoms, incorporating both non-pharmacological and pharmacological treatments 5.
- Non-pharmacological treatments should be considered as the first-line approach, with pharmacological treatments used only when necessary and with careful consideration of the potential risks and benefits 2, 3, 5.
Vascular Dementia
- There is limited evidence available on the treatment of neuropsychiatric symptoms in vascular dementia, and more research is needed to determine the most effective treatments for this population 2.