What additional treatments can be added to manage agitation and behavioral disturbances in a 76‑year‑old woman with anxiety disorder, major depressive disorder, schizoaffective disorder (depressive type) and dementia who is currently on lorazepam (Ativan) 2 mg up to three times daily, buspirone (Buspar) 10 mg up to three times daily, duloxetine (Cymbalta) 30 mg daily, melatonin 6 mg at bedtime, and quetiapine (Seroquel) 100 mg twice daily?

Management of Behavioral Disturbances in Elderly Patient with Dementia and Schizoaffective Disorder

Critical First Step: Discontinue Lorazepam Immediately

The American Geriatrics Society explicitly recommends against using benzodiazepines for routine agitation management in elderly dementia patients—lorazepam 2 mg three times daily is excessive, dangerous, and likely worsening her confusion and agitation rather than helping. 1 Benzodiazepines increase delirium incidence and duration, cause paradoxical agitation in approximately 10% of elderly patients, worsen cognitive function, and increase fall risk. 1 Taper the lorazepam gradually over 2-4 weeks while monitoring closely for withdrawal symptoms, as abrupt discontinuation can produce rebound insomnia and agitation. 1

Immediate Medical Investigation Required Before Any Medication Changes

Before adding anything, systematically investigate reversible medical causes that commonly drive behavioral disturbances in dementia patients who cannot verbally communicate discomfort:

• Pain assessment and management is the single most important contributor to behavioral disturbances and must be addressed first. 1
• Check for urinary tract infection and pneumonia—infections are disproportionately common contributors to neuropsychiatric symptoms in dementia patients. 1
• Evaluate for constipation and urinary retention—both significantly contribute to restlessness and aggression. 1
• Review all medications for anticholinergic properties—diphenhydramine, hydroxyzine, oxybutynin, and cyclobenzaprine worsen confusion and agitation and should be discontinued. 1
• Check for dehydration, electrolyte abnormalities, and metabolic disturbances. 1

Current Medication Regimen Assessment

Your patient is already on multiple psychotropics with significant overlap and polypharmacy concerns:

• Buspirone 10 mg three times daily has limited evidence for behavioral and psychological symptoms of dementia (BPSD) and may contribute to polypharmacy without clear benefit. 1 Buspirone takes 2-4 weeks to become effective and is useful only for mild to moderate agitation, not severe behavioral disturbances. 1 Consider tapering this medication as it is unlikely providing meaningful benefit for her severe symptoms.

• Duloxetine 30 mg daily is underdosed for treating depression or chronic agitation. The American Psychiatric Association recommends SSRIs as first-line pharmacological treatment for chronic agitation in dementia, but duloxetine is an SNRI with a different side effect profile. 1 If continuing an antidepressant approach, switching to an SSRI at therapeutic doses would be more evidence-based.

• Quetiapine 100 mg twice daily is already at a moderate dose. The American Academy of Family Physicians notes quetiapine has more sedating effects and risk of transient orthostasis, and patients over 75 years respond less well to antipsychotics, particularly olanzapine. 1

Recommended Medication Strategy

Switch from duloxetine to sertraline 25-50 mg daily, titrating to a maximum of 200 mg daily over 4-8 weeks, as SSRIs are the preferred first-line pharmacological treatment for chronic agitation in dementia. 1 The American Academy of Family Physicians recommends sertraline as the top choice due to minimal drug interactions, excellent tolerability, and significant benefits in cognitive functioning and quality of life. 1 Sertraline requires 4-8 weeks for full therapeutic effect at adequate dosing. 1

If behavioral symptoms remain severe after optimizing sertraline and discontinuing lorazepam, consider adding low-dose risperidone 0.25 mg once daily at bedtime, titrating to a target dose of 0.5-1.25 mg daily only if absolutely necessary. 1 The American Academy of Family Physicians recommends risperidone as first-line pharmacological option for severe agitation with psychotic features in dementia, but only when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed. 1

Critical Safety Discussion Required

Before initiating or continuing any antipsychotic, you must discuss with the patient's surrogate decision maker the increased mortality risk (1.6-1.7 times higher than placebo), cardiovascular effects including QT prolongation and sudden death, cerebrovascular adverse reactions, falls risk, and metabolic changes. 1 All antipsychotics increase mortality risk in elderly patients with dementia. 1

Non-Pharmacological Interventions Must Be Implemented Simultaneously

The American Geriatrics Society emphasizes that behavioral interventions must be attempted and documented as failed or impossible before relying solely on medications:

• Use calm tones, simple one-step commands, and gentle touch for reassurance rather than complex multi-step instructions. 1
• Ensure adequate lighting and reduce excessive noise to minimize overstimulation. 1
• Establish predictable daily routines including structured bedtime routine. 1
• Increase daytime bright light exposure to 2 hours of morning bright light at 3,000-5,000 lux to decrease daytime napping and reduce agitated behavior. 1
• Provide at least 30 minutes of sunlight exposure daily and increase supervised mobility. 1
• Use ABC (antecedent-behavior-consequence) charting to identify specific triggers of her screaming and crying. 1

Monitoring and Reassessment Protocol

• Evaluate response to sertraline within 4 weeks using quantitative measures such as the Cohen-Mansfield Agitation Inventory or Neuropsychiatric Inventory Questionnaire (NPI-Q). 1
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication. 1
• Daily in-person examination to evaluate ongoing need for any antipsychotic and assess for side effects. 1
• Monitor for extrapyramidal symptoms, falls, sedation, metabolic changes, QT prolongation, and cognitive worsening. 1
• Attempt taper of quetiapine within 3-6 months to determine if still needed, as approximately 47% of patients continue receiving antipsychotics after discharge without clear indication. 1

What NOT to Do

• Do not add haloperidol or other typical antipsychotics—the American Academy of Family Physicians recommends avoiding typical antipsychotics as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients. 1
• Do not continue lorazepam—benzodiazepines should not be used for routine agitation management except for alcohol or benzodiazepine withdrawal. 1
• Do not add multiple psychotropics simultaneously without first treating reversible medical causes and optimizing existing medications. 1
• Do not use antipsychotics for mild agitation or behaviors like repetitive questioning or wandering—these are unlikely to respond to psychotropics. 1

Addressing Her Specific Symptoms

Her crying about not remembering her father likely represents grief related to her dementia progression and memory loss. This requires:

• Validation of her emotional distress rather than correction or reorientation. 1
• Frequent reassurance and gentle touch using calm tones. 1
• Caregiver education that behaviors are symptoms of dementia, not intentional actions. 1
• Consideration that this may represent underlying depression requiring adequate SSRI dosing (sertraline up to 200 mg daily). 1