What are the recommended strategies to manage anxiety and agitation in a patient with dementia?

Management of Anxiety and Agitation in Dementia

First-Line: Non-Pharmacological Interventions Are Mandatory

Non-pharmacological interventions must be attempted first and documented as failed before any medication is considered, unless there is imminent risk of harm to self or others. 1

Systematic Investigation of Reversible Medical Causes

Before implementing any behavioral strategy or medication, aggressively search for and treat underlying medical triggers that commonly drive anxiety and agitation in dementia patients who cannot verbally communicate discomfort:

• Pain assessment and management is the single most critical factor—untreated pain is a major contributor to behavioral disturbances and must be addressed systematically before considering psychotropic adjustments 1, 2
• Infections are disproportionately common triggers: check for urinary tract infections and pneumonia immediately 1, 2
• Metabolic disturbances including dehydration, electrolyte abnormalities, hypoxia, and hyperglycemia worsen confusion and behavioral symptoms 1
• Constipation and urinary retention significantly contribute to restlessness and agitation 1, 2
• Medication review to identify and discontinue anticholinergic agents (diphenhydramine, hydroxyzine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 1

Environmental and Communication Modifications

• Establish predictable daily routines with regular exercise, meals, and consistent sleep schedules 2
• Ensure adequate lighting and reduce excessive noise to minimize overstimulation 1, 2
• Use calm tones, simple one-step commands, and gentle touch for reassurance—avoid complex multi-step instructions, open-ended questions, or yelling 1, 2
• Allow adequate time for the patient to process information before expecting a response 1
• Simplify the environment with clear labels, color-coded storage, and structured layouts to reduce confusion 2
• Install safety equipment (grab bars, handrails) and remove hazardous items 2

Caregiver Education

• Educate caregivers that behaviors are symptoms of dementia, not intentional actions, to promote empathy and understanding 1
• Provide psychoeducational interventions with active participation training for family caregivers 1

---

Second-Line: Pharmacological Treatment (Only After Non-Pharmacological Failure)

When to Consider Medications

Medications should only be used when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have been thoroughly attempted and documented as insufficient. 1

Appropriate indications for pharmacological treatment include:

• Severe agitation with imminent risk of harm to self or others 1
• Major depression with or without suicidal ideation 1
• Psychosis causing harm or with great potential of harm 1
• Aggression causing imminent risk 1

Do NOT use medications for: unfriendliness, poor self-care, memory problems, inattention, repetitive verbalizations/questioning, rejection of care, shadowing, or wandering—these are unlikely to respond to psychotropics 1

Medication Selection Algorithm

For Chronic Agitation WITHOUT Psychotic Features: SSRIs First-Line

SSRIs are the preferred first-line pharmacological option for chronic anxiety and agitation in dementia. 1

• Citalopram: Start 10 mg/day, maximum 40 mg/day 1
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day 1

Advantages of SSRIs:

• Significantly reduce overall neuropsychiatric symptoms, agitation, and depression in vascular cognitive impairment and dementia 1
• Well tolerated with less effect on metabolism of other medications (sertraline) 1
• Lower mortality risk compared to antipsychotics 1

Monitoring: Evaluate response within 4 weeks using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q); if no clinically significant response after 4 weeks at adequate dose, taper and withdraw 1

For Severe Agitation WITH Psychotic Features: Antipsychotics (With Extreme Caution)

Antipsychotics should only be used when SSRIs and behavioral approaches have failed, and only for severe, dangerous symptoms. 1

Critical Safety Discussion Required: Before initiating any antipsychotic, discuss with the patient (if feasible) and surrogate decision maker:

• Increased mortality risk (1.6-1.7 times higher than placebo) 1
• Cardiovascular effects including QT prolongation, dysrhythmias, sudden death 1
• Cerebrovascular adverse reactions (stroke risk) 1
• Falls, hypotension, pneumonia, metabolic changes 1

Preferred Antipsychotic Options:

• Risperidone: Start 0.25 mg once daily at bedtime, target dose 0.5-1.25 mg daily (maximum 2-3 mg/day); extrapyramidal symptoms increase above 2 mg/day 1
• Quetiapine: Start 12.5 mg twice daily, maximum 200 mg twice daily; more sedating with risk of orthostatic hypotension 1
• Olanzapine: Start 2.5 mg at bedtime, maximum 10 mg/day; less effective in patients over 75 years 1

For Acute Severe Agitation with Imminent Harm:

• Haloperidol: 0.5-1 mg orally or subcutaneously, maximum 5 mg daily in elderly patients 1

Monitoring: Use the lowest effective dose for the shortest possible duration, with daily in-person evaluation; attempt taper within 3-6 months 1

Alternative Option: Trazodone

• Trazodone: Start 25 mg/day, maximum 200-400 mg/day in divided doses; use caution in patients with premature ventricular contractions due to orthostatic hypotension risk 1

What NOT to Use

Benzodiazepines should be avoided for routine agitation management (except for alcohol or benzodiazepine withdrawal) due to:

• Increased delirium incidence and duration 1
• Paradoxical agitation in approximately 10% of elderly patients 1
• Risk of tolerance, addiction, cognitive impairment, respiratory depression, and falls 1

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 1

---

Critical Pitfalls to Avoid

• Never add medications without first treating reversible medical causes (pain, infection, metabolic disturbances) 1
• Never rely exclusively on pharmacological interventions without implementing non-pharmacological strategies 1, 2
• Never continue antipsychotics indefinitely—review need at every visit and taper if no longer indicated 1
• Never use antipsychotics for mild agitation—reserve for severe symptoms that are dangerous or cause significant distress 1
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—inadvertent chronic use must be avoided 1