From the Guidelines
For an 83-year-old female with Alzheimer's disease experiencing severe agitation that is not responding to Ativan (lorazepam), the next best step would be to initiate an atypical antipsychotic medication, specifically risperidone (Risperdal) starting at a low dose of 0.25mg daily with careful titration as needed, as recommended by the American Psychiatric Association practice guideline 1. This approach is preferred over continuing to increase benzodiazepines, which can worsen cognitive function and increase fall risk in elderly patients. According to the guideline, antipsychotic medications can be appropriate in individuals with dementia, particularly in those with dangerous agitation or psychosis, and can minimize the risk of violence, reduce patient distress, improve patient’s quality of life, and reduce caregiver burden 1. The medication should be started at a low dose and increased gradually while monitoring for side effects such as sedation, orthostatic hypotension, and extrapyramidal symptoms. Some key points to consider when using antipsychotics in elderly patients with dementia include:
- Starting with a low dose and titrating carefully to minimize side effects
- Monitoring for side effects such as sedation, orthostatic hypotension, and extrapyramidal symptoms
- Using the medication at the lowest effective dose for the shortest duration possible due to the increased risk of mortality in elderly patients with dementia 1
- Considering alternative medications such as quetiapine (Seroquel) or olanzapine (Zyprexa) if risperidone is not effective or well-tolerated, as suggested by the guidelines for managing Alzheimer's disease 1 Non-pharmacological approaches should also be continued simultaneously, including:
- Maintaining a consistent routine
- Creating a calm environment
- Identifying and addressing triggers for agitation
- Providing appropriate sensory stimulation It's essential to weigh the potential benefits and harms of antipsychotic medication in each individual patient, considering their unique circumstances and clinical presentation, as emphasized by the American Psychiatric Association practice guideline 1.
From the Research
Next Best Step for Alzheimer's Patient with Severe Agitation
- The patient is not responding to Ativan, which is often used to treat agitation in Alzheimer's patients.
- According to the study 2, dextromethorphan/quinidine, risperidone, and selective serotonin reuptake inhibitors (SSRIs) as a class were found to be significantly more efficacious than placebo in alleviating agitation in dementia patients.
- The study 2 also found that haloperidol appeared less efficacious than nearly all comparators, and oxcarbazepine was inferior in terms of treatment continuation.
- Another study 3 found that SSRIs, including escitalopram, paroxetine, and sertraline, significantly alleviated depressive symptoms in AD patients, which may be related to agitation.
Considerations for Treatment
- The decision to prescribe should be based on comprehensive consideration of the benefits and risks, including those not evaluated in the meta-analysis 2.
- It is essential to consider the individual patient's response to treatment and adjust the treatment plan accordingly.
- The studies 4, 5, and 6 provide additional context for the use of SSRIs in Alzheimer's patients, but the primary focus for agitation treatment should be on the findings from 2.