What is the recommended assessment and management for aggression in a patient with dementia?

Assessment and Management of Aggression in Dementia

Begin with systematic investigation of reversible medical causes—particularly pain, infections (UTI, pneumonia), constipation, urinary retention, and dehydration—before considering any psychotropic medication, as these are the primary drivers of aggressive behavior in patients who cannot verbally communicate discomfort. 1

Initial Assessment: Rule Out Reversible Medical Triggers

Pain assessment is the highest priority and must be addressed before any medication adjustments, as untreated pain is a major contributor to behavioral disturbances in dementia patients. 1 Systematically evaluate for:

• Infections: Check for urinary tract infections and pneumonia, which are disproportionately common triggers of aggression in this population. 1
• Metabolic disturbances: Assess for dehydration, electrolyte abnormalities, hypoxia, and hyperglycemia. 1
• Constipation and urinary retention: Both significantly contribute to restlessness and aggressive behavior. 1
• Medication review: Identify and discontinue anticholinergic agents (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation. 1
• Sensory impairments: Address hearing and vision problems that increase confusion and fear. 1

Use the Neuropsychiatric Inventory Questionnaire (NPI-Q) to quantify baseline severity and establish objective measures for monitoring treatment response. 2

Non-Pharmacological Interventions (First-Line Treatment)

Non-pharmacological interventions must be attempted and documented as failed before considering medications, unless there is imminent risk of harm to self or others. 1, 3

Communication and Environmental Modifications

• Use calm tones, simple one-step commands, and gentle touch for reassurance rather than complex multi-step instructions. 1
• Allow adequate time for the patient to process information before expecting a response. 1
• Avoid confrontational approaches that escalate resistance. 1
• Ensure adequate lighting and reduce excessive noise to minimize overstimulation. 1
• Provide predictable daily routines with structured activities tailored to individual abilities and previous interests. 1

Activity-Based Interventions

• Ensure at least 30 minutes of supervised mobility and sunlight exposure daily to provide temporal cues and reduce agitation. 1
• Use ABC (antecedent-behavior-consequence) charting to identify specific triggers of aggressive behavior. 1
• Install safety equipment (grab bars, bath mats) and remove hazardous items. 1

Caregiver Education

• Educate caregivers that behaviors are symptoms of dementia, not intentional actions, to promote empathy and understanding. 4
• Involve caregivers actively in planning and implementing behavioral interventions. 5

Pharmacological Treatment (Second-Line)

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, 3

First-Line Pharmacological: SSRIs for Chronic Agitation

If non-pharmacological interventions fail after an adequate trial, initiate an SSRI as first-line pharmacological treatment for chronic agitation without psychotic features. 1

• Citalopram: Start 10 mg/day, maximum 40 mg/day. Well-tolerated, though some patients experience nausea and sleep disturbances. 1, 3
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day. Well-tolerated with less effect on metabolism of other medications. 1, 3

SSRIs significantly reduce overall neuropsychiatric symptoms, agitation, and depression in dementia patients with a substantially better safety profile than antipsychotics. 1

Evaluate response within 4 weeks using quantitative measures (NPI-Q or Cohen-Mansfield Agitation Inventory). If no clinically significant response after 4 weeks at adequate dose, taper and withdraw. 1, 3

Second-Line: Antipsychotics for Severe Agitation with Psychosis

Antipsychotics should only be used when the patient is severely agitated with psychotic features, threatening substantial harm to self or others, and both behavioral interventions and SSRI trial have failed. 1, 3

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, 3
• Cardiovascular effects including QT prolongation, dysrhythmias, sudden death 1, 3
• Cerebrovascular adverse reactions 3
• Falls risk and metabolic changes 1, 3

Risperidone (preferred for severe agitation with psychotic features):

• Start 0.25 mg once daily at bedtime
• Target dose 0.5-1.25 mg daily
• Extrapyramidal symptoms increase significantly at doses >2 mg/day 1, 3

Quetiapine (alternative):

• Start 12.5 mg twice daily
• Maximum 200 mg twice daily
• More sedating with risk of transient orthostasis 3

Olanzapine (alternative):

• Start 2.5 mg at bedtime
• Maximum 10 mg/day
• Less effective in patients over 75 years 3

Acute Agitation with Imminent Risk of Harm

For severe acute agitation with imminent risk of harm when non-pharmacological interventions have failed:

Haloperidol 0.5-1 mg orally or subcutaneously, maximum 5 mg daily in elderly patients. 1, 3

Avoid benzodiazepines as first-line treatment (except for alcohol or benzodiazepine withdrawal) because they:

• Increase delirium incidence and duration 1, 3
• Cause paradoxical agitation in approximately 10% of elderly patients 1, 3
• Worsen cognitive function 1, 3
• Risk respiratory depression, tolerance, and addiction 1, 3

Medications to AVOID

Never use typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients. 3

Avoid benzodiazepines for routine agitation management due to the risks outlined above. 1, 3

Monitoring and Duration of Treatment

For SSRIs:

• Evaluate response within 4 weeks using quantitative measures 1, 3
• Monitor for side effects including nausea, sleep disturbances, and falls 1
• Continue if providing clinically meaningful benefit 3
• Periodically reassess need for continued medication 3

For Antipsychotics:

• Use the lowest effective dose for the shortest possible duration 1, 3
• Evaluate ongoing need daily with in-person examination 1, 3
• Attempt taper within 3-6 months to determine the lowest effective maintenance dose 1, 3
• Monitor for extrapyramidal symptoms, falls, metabolic changes, QT prolongation, and cognitive worsening 1, 3
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—avoid inadvertent chronic use 3

Common Pitfalls to Avoid

• Never add psychotropics without first treating reversible medical causes (pain, infection, metabolic disturbances). 1
• Do not use antipsychotics for mild agitation or behaviors like unfriendliness, poor self-care, repetitive questioning, or wandering—these are unlikely to respond to psychotropics. 1
• Avoid continuing antipsychotics indefinitely—review need at every visit and taper if no longer indicated. 3
• Do not underestimate pain and discomfort as causes of behavioral disturbances. 4
• Recognize that behaviors are symptoms of dementia, not intentional actions requiring punishment or restraint. 4, 5