From the Guidelines
Treatment for dementia with agitation should prioritize non-pharmacological approaches, with selective serotonin reuptake inhibitors (SSRIs) considered as first-line pharmacological treatment for agitation, due to their ability to reduce overall neuropsychiatric symptoms and agitation, as evidenced by the most recent study 1.
Non-Pharmacological Approaches
When managing dementia with agitation, it is essential to start by creating a calm, structured environment with consistent routines, familiar objects, and adequate lighting. Identifying and addressing potential triggers of agitation, such as pain, hunger, fatigue, or overstimulation, is also crucial. Engaging the person in meaningful activities, music therapy, or reminiscence therapy can help reduce agitation. Simulated presence therapy (SPT), using audio or video recordings prepared by family members or surrogates, and including positive experiences from the participant’s past life, can also reduce symptoms of agitation in individuals with severe dementia living in nursing homes, as noted in 1.
Pharmacological Treatment
When medications become necessary, SSRIs, such as citalopram (10-20mg daily), are considered first-line treatments for agitation in individuals with dementia, due to their ability to significantly reduce overall neuropsychiatric symptoms and agitation, as found in the most recent study 1. For severe agitation, low-dose antipsychotics, such as risperidone (0.25-0.5mg once or twice daily), quetiapine (25-50mg once or twice daily), or olanzapine (2.5-5mg daily), may be considered, but should be used at the lowest effective dose for the shortest time possible due to increased mortality risk in elderly patients with dementia, as cautioned in 1 and 1. Regular reassessment is crucial to monitor effectiveness and side effects.
Caregiver Education and Support
Caregiver education and support are essential components of treatment, as they can learn techniques to prevent and manage agitation episodes. The goal is to maintain dignity and quality of life while minimizing distress for both the person with dementia and their caregivers. By prioritizing non-pharmacological approaches and using SSRIs as first-line pharmacological treatment, healthcare providers can improve outcomes for individuals with dementia and agitation, as supported by the most recent evidence 1.
From the FDA Drug Label
WARNINGS AND PRECAUTIONS SECTION 5. 1 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. RISPERIDONE (risperidone) is not approved for the treatment of dementia-related psychosis [see Boxed Warning].
The FDA drug label does not support the use of Risperidone for the treatment of dementia with agitation due to the increased risk of mortality in elderly patients with dementia-related psychosis 2.
- Key points:
- Increased risk of death in elderly patients with dementia-related psychosis
- RISPERIDONE is not approved for the treatment of dementia-related psychosis
- Cerebrovascular adverse reactions, including stroke, have been reported in patients with dementia-related psychosis treated with risperidone. The use of risperidone in patients with dementia-related psychosis is not recommended due to the potential risks.
From the Research
Non-Pharmacological Interventions for Dementia with Agitation
- Non-pharmacological interventions are being increasingly implemented to manage agitation in people with dementia due to the limited effectiveness and adverse reactions of medications 3, 4.
- Massage therapy, animal-assisted intervention, and personally tailored intervention have been associated with substantial reductions in agitation compared to other interventions and controls 3.
- Person-centred care, communication skills training, and adapted dementia care mapping have also been shown to decrease symptomatic and severe agitation in care homes 4.
- Activities and music therapy by protocol have been found to decrease overall agitation, while sensory intervention has been shown to decrease clinically significant agitation immediately 4.
Pharmacological Interventions for Dementia with Agitation
- SSRI medications have been investigated as an alternative psychopharmacological approach to manage neuropsychiatric symptoms of dementia, including agitation 5.
- Acetylcholinesterase inhibitors and memantine may be initiated to enhance cognition, and trazodone may be used to manage insomnia or sundowning 6.
- Citalopram and low doses of atypical antipsychotics such as risperidone or quetiapine may be effective in managing agitation, but potential adverse effects must be considered 6.
Comparison of Interventions
- Music therapy has been found to be the most effective non-pharmacological intervention for reducing agitation/aggressive behaviour in people with dementia, followed by aromatherapy and massage, and finally physical exercise 7.
- Non-pharmacological interventions such as massage therapy, animal-assisted intervention, and personally tailored intervention may be more effective than pharmacological interventions in managing agitation in people with dementia 3, 4.