What medications are used to manage yelling and screaming in patients with neurodegenerative disorders, such as dementia, or neurodevelopmental disorders, such as autism?

Medications for Managing Yelling and Screaming

Non-pharmacological interventions must be attempted first and documented as failed before considering medications, with SSRIs (citalopram or sertraline) as first-line pharmacological treatment for chronic agitation, and low-dose haloperidol (0.5-1 mg) reserved only for severe acute agitation with imminent risk of harm to self or others. 1, 2

Critical First Step: Identify and Treat Reversible Causes

Before any medication is considered, systematically investigate and address underlying medical triggers that commonly drive yelling and screaming in patients who cannot verbally communicate discomfort 1, 2:

• Pain assessment and management - a major contributor to behavioral disturbances that must be addressed first 1, 2
• Infections - particularly urinary tract infections and pneumonia 1, 2
• Metabolic disturbances - dehydration, electrolyte abnormalities, hypoxia, hyperglycemia 2
• Constipation and urinary retention - significant contributors to restlessness and agitation 2
• Medication review - identify and discontinue anticholinergic agents (diphenhydramine, hydroxyzine, oxybutynin) that worsen confusion and agitation 2
• Sensory impairments - hearing or vision problems that increase confusion and fear 2

Non-Pharmacological Interventions (First-Line Treatment)

These approaches have substantial evidence for efficacy without mortality risks associated with medications 1, 2:

Environmental Modifications

• Ensure adequate lighting and reduce excessive noise 1, 2
• Provide structured daily routines and predictable schedules 2
• Use safety equipment (grab bars, bath mats) to prevent injuries 2
• Simplify the environment with clear labels and structured layouts 2

Communication Strategies

• Use calm tones and simple one-step commands instead of complex multi-step instructions 1, 2
• Allow adequate time for the patient to process information before expecting a response 1, 2
• Avoid harsh tones, screaming, or open-ended questioning 1

Behavioral Approaches

• Use ABC (antecedent-behavior-consequence) charting to identify specific triggers 2
• Modify or eliminate triggers of agitation 1
• Provide at least 30 minutes of sunlight exposure daily 2
• Increase supervised mobility and structured activities 2

Pharmacological Treatment Algorithm

When Medications Are Indicated

Medications should only be used in three specific circumstances 1:

1. Major depression with or without suicidal ideation
2. Psychosis causing harm or with great potential of harm
3. Aggression causing imminent risk to self or others

First-Line: SSRIs for Chronic Agitation

For chronic yelling and screaming without psychotic features, SSRIs are the preferred pharmacological option 2:

• Citalopram: Start 10 mg/day, maximum 40 mg/day 2
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day 2

Key points about SSRI use:

• Initiate at low dose and titrate to minimum effective dose 2
• Allow 4 weeks at adequate dosing before assessing response 2
• Use quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) to assess baseline severity and monitor response 2
• If no clinically significant response after 4 weeks, taper and withdraw 2
• Even with positive response, periodically reassess need for continued medication 2

Second-Line: Antipsychotics for Severe Acute Agitation

Antipsychotics should only be used when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed 1, 2:

For Acute Severe Agitation:

• Haloperidol: 0.5-1 mg orally or subcutaneously, maximum 5 mg daily in elderly patients 2, 3
  • Preferred over other options due to extensive evidence base since 1973 3
  • Lower risk of respiratory depression compared to benzodiazepines 2

For Chronic Severe Agitation with Psychotic Features:

• Risperidone: Start 0.25 mg once daily at bedtime, target dose 0.5-1.25 mg daily 2

  • Risk of extrapyramidal symptoms increases above 2 mg/day 2, 4
  • Patients over 75 years respond less well to antipsychotics, particularly olanzapine 2

• Quetiapine: Start 12.5 mg twice daily, maximum 200 mg twice daily 2

  • More sedating with risk of orthostatic hypotension 2

Alternative Options (Third-Line):

• Trazodone: Start 25 mg/day, maximum 200-400 mg/day in divided doses 2
  • Use caution in patients with premature ventricular contractions 2
  • Takes 2-4 weeks to become effective 2

Critical Safety Warnings

Mandatory Risk Discussion Before Initiating Antipsychotics

Before starting any antipsychotic, discuss with patient (if feasible) and surrogate decision maker 2:

• Increased mortality risk (1.6-1.7 times higher than placebo) 2
• Cardiovascular effects including QT prolongation, dysrhythmias, sudden death 2
• Cerebrovascular adverse reactions 2
• Risk of falls, pneumonia, and metabolic effects 2
• Expected benefits and treatment goals 2

Dosing and Duration Principles

• Use the lowest effective dose for the shortest possible duration 2
• Evaluate daily with in-person examination 2
• Attempt taper within 3-6 months to determine if still needed 2
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication - avoid inadvertent chronic use 2

Monitoring Requirements

• Extrapyramidal symptoms (tremor, rigidity, bradykinesia) 2
• Falls risk assessment at each visit 2
• Metabolic changes 2
• QT prolongation with ECG monitoring 2
• Cognitive worsening 2

What NOT to Use

Benzodiazepines should be avoided as first-line treatment except for alcohol or benzodiazepine withdrawal 1, 2:

• Increase delirium incidence and duration 2
• Cause paradoxical agitation in approximately 10% of elderly patients 2
• Risk of tolerance, addiction, cognitive impairment, and respiratory depression 2
• Can worsen cognitive function in dementia patients 2

Typical antipsychotics (haloperidol, fluphenazine, thiothixene) should be avoided as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 2

Anticholinergic medications (diphenhydramine, hydroxyzine, oxybutynin) worsen agitation and cognitive function and should be discontinued 2

Common Pitfalls to Avoid

• Never add medications without first treating reversible medical causes - pain, infections, constipation, and urinary retention are disproportionately common contributors 1, 2
• Do not use antipsychotics for mild agitation or behaviors like unfriendliness, poor self-care, memory problems, repetitive questioning, or wandering - these are unlikely to respond to psychotropics 1, 2
• Avoid continuing antipsychotics indefinitely - review need at every visit and taper if no longer indicated 2
• Do not add multiple psychotropics simultaneously without first optimizing existing regimen and attempting non-pharmacological interventions 2
• Never skip the risk/benefit discussion with patient or surrogate before initiating antipsychotics 2

Special Populations

Dementia Patients

• Psychotropics are unlikely to impact repetitive verbalizations/questioning, rejection of care, shadowing, or wandering 1
• Environmental and behavioral modifications are essential first steps 1, 2
• Caregiver education that behaviors are symptoms of dementia, not intentional actions, promotes empathy and understanding 2

Pediatric Patients with Autism or Developmental Disorders

• Verbal de-escalation and behavioral interventions are first-line 1
• For acute severe agitation: combination of benzodiazepine and antipsychotic may be used 1
• Risperidone is FDA-approved for irritability associated with autistic disorder in children aged 5-16 years 4
• All controlled trials of medications for acute agitation have been conducted with adults - pediatric use is extrapolated 1