What are the most effective non‑pharmacologic strategies to prevent an older adult with dementia from moving or hiding items, and when is low‑dose antipsychotic medication (e.g., risperidone) appropriate?

Managing Item-Moving and Hiding Behaviors in Dementia

Start with Non-Pharmacological Interventions—These Are First-Line and Must Be Exhausted First

Behavioral and environmental modifications are the foundation of managing item-moving and hiding behaviors in dementia, and medications should only be considered when the patient is severely agitated, threatening substantial harm to self or others, and these non-pharmacological approaches have been systematically attempted and documented as insufficient. 1

Immediate Environmental and Behavioral Strategies

• Establish a predictable daily routine with consistent timing for meals, exercise, and bedtime to reduce confusion and anxiety that often drives these behaviors 2, 1

• Simplify the environment by reducing clutter, removing excess stimulation, and creating clearly labeled storage areas with color-coded or graphic labels on closets, drawers, and cabinets 2, 1

• Allow the patient to keep personal possessions in their own space and dress in their own clothing, as restricting access often increases anxiety and hiding behaviors 2

• Use the "three R's" approach: Repeat instructions calmly, Reassure the patient, and Redirect their attention to another activity when you observe item-moving behavior starting 2, 3

• Install safety measures including locks on doors/gates and remove hazardous items, but ensure the patient has a designated "safe space" where they can move items without danger 2, 1

• Provide adequate lighting throughout the day and especially at night, as poor lighting increases confusion and disorientation that can worsen these behaviors 2, 1

• Reduce excessive environmental stimuli by minimizing noise from television, avoiding glare from windows and mirrors, and limiting outings to crowded places 2, 3

Critical Medical Investigation Before Any Medication

Before considering any pharmacological intervention, systematically investigate and treat reversible medical causes that commonly drive behavioral disturbances in dementia patients who cannot verbally communicate discomfort: 1

• Pain assessment and management is a major contributor to behavioral disturbances and must be addressed first 1

• Check for infections, particularly urinary tract infections and pneumonia, which disproportionately trigger behavioral symptoms in dementia 1

• Evaluate for constipation and urinary retention, both of which significantly contribute to restlessness and agitation 1

• Review all medications to identify and discontinue anticholinergic agents (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 1

• Assess for metabolic disturbances including dehydration, electrolyte abnormalities, and hypoxia 1

• Correct sensory impairments (hearing aids, glasses) as these increase confusion and fear 1

When Pharmacological Treatment Becomes Necessary

Indications for Medication—Use Only in Specific Circumstances

Medications should only be considered when: 1

• The patient is severely agitated, distressed, or threatening substantial harm to self or others
• Behavioral interventions have been thoroughly attempted and documented as insufficient
• The behaviors are causing dangerous situations or significant distress to the patient
• You are dealing with severe agitation with psychotic features (delusions, hallucinations) rather than simple item-moving

First-Line Pharmacological Option: SSRIs for Chronic Agitation

For chronic agitation without psychotic features, SSRIs are the preferred first-line pharmacological treatment: 1

• Citalopram: Start 10 mg/day, maximum 40 mg/day 1

• Sertraline: Start 25-50 mg/day, maximum 200 mg/day 1

• Assess response after 4 weeks at adequate dosing using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) 1

• If no clinically significant response after 4 weeks, taper and withdraw the medication 1

Second-Line: Low-Dose Antipsychotics—Reserved for Severe, Dangerous Agitation

Antipsychotics should only be used when the patient is severely agitated with psychotic features, threatening substantial harm, and SSRIs plus behavioral interventions have failed: 1

Risperidone (Preferred Antipsychotic)

• Start 0.25 mg once daily at bedtime 1, 4
• Target dose 0.5-1.25 mg daily (mean effective dose ~1 mg/day) 5, 4
• Maximum 2-3 mg/day in divided doses 1
• Extrapyramidal symptoms increase significantly above 2 mg/day 1, 6

Critical Safety Discussion Required Before Starting Any Antipsychotic

You must discuss with the patient (if feasible) and surrogate decision maker: 1

• Increased mortality risk (1.6-1.7 times higher than placebo) in elderly dementia patients 1
• Cardiovascular risks including QT prolongation, sudden death, dysrhythmias, hypotension 1
• Cerebrovascular adverse events including stroke risk 1, 7
• Falls risk, metabolic changes, and extrapyramidal symptoms 1

Duration and Monitoring

• Use the lowest effective dose for the shortest possible duration 1
• Evaluate daily with in-person examination to assess ongoing need and side effects 1
• Attempt taper within 3-6 months to determine if still needed, as approximately 47% of patients continue receiving antipsychotics without clear indication 1
• Monitor for extrapyramidal symptoms, falls, sedation, metabolic changes, and QT prolongation 1

What NOT to Use

• Avoid benzodiazepines for routine agitation management due to increased delirium, paradoxical agitation in ~10% of elderly patients, cognitive impairment, and falls risk 1, 3

• Avoid typical antipsychotics (haloperidol, fluphenazine) as first-line due to 50% risk of tardive dyskinesia after 2 years of continuous use 1, 3

Common Pitfalls to Avoid

• Do not add medications without first exhausting behavioral interventions and treating reversible medical causes 1

• Do not continue antipsychotics indefinitely—review need at every visit and taper if no longer indicated 1

• Do not use antipsychotics for mild behaviors like unfriendliness, poor self-care, repetitive questioning, or simple wandering—these are unlikely to respond to psychotropics 1

• Do not combine multiple psychotropics simultaneously without clear indication, as this increases adverse effects without demonstrated benefit 1