In an elderly woman with Alzheimer disease who is exhibiting aggressive behavior, what medication should be started?

Management of Aggressive Behavior in Elderly Female with Alzheimer's Disease

Start with an SSRI—specifically citalopram 10 mg daily or sertraline 25–50 mg daily—as your first-line pharmacological treatment for chronic aggressive behavior in this elderly woman with Alzheimer's disease, but only after you have systematically ruled out and treated reversible medical causes (pain, infection, constipation, urinary retention) and attempted non-pharmacological interventions. 1

Critical First Steps: Investigate Reversible Medical Causes

Before prescribing any medication, you must systematically evaluate and treat underlying medical contributors that commonly drive aggressive behavior in dementia patients who cannot verbally communicate discomfort:

• Pain assessment is your highest priority—untreated pain is a major contributor to behavioral disturbances and must be addressed before considering any psychotropic medication 1, 2
• Check for urinary tract infections and pneumonia, which are disproportionately common triggers of acute behavioral changes in elderly dementia patients 1
• Evaluate for constipation and urinary retention, both of which significantly contribute to restlessness and aggression 1
• Screen for dehydration and metabolic disturbances (electrolyte abnormalities, hypoxia, hyperglycemia) that worsen confusion 1
• Review all current medications to identify and discontinue anticholinergic agents (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 1
• Assess for sensory impairments (hearing loss, vision problems) that increase confusion and fear 1

Non-Pharmacological Interventions (Mandatory First-Line)

The American Geriatrics Society and American Psychiatric Association require that behavioral and environmental interventions be attempted and documented as failed before initiating pharmacological treatment 1:

• 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
• Ensure adequate lighting and reduce excessive noise to minimize overstimulation 1
• Provide predictable daily routines with structured activities tailored to individual abilities 1
• Use ABC (antecedent-behavior-consequence) charting to identify specific triggers of aggressive behavior over several days 1, 2
• Install safety equipment (grab bars, handrails) and remove hazardous items 1
• Ensure at least 30 minutes of supervised mobility and sunlight exposure daily to provide temporal cues 1

Staff training programs and environmental modifications appear to be the most effective non-pharmacological strategies for managing aggressive behavior in long-term care settings 3.

First-Line Pharmacological Treatment: SSRIs

When non-pharmacological interventions are insufficient after an adequate trial (generally 24–48 hours to several weeks depending on severity), initiate an SSRI as your preferred first-line medication 1:

Citalopram

• Start at 10 mg daily, maximum 40 mg daily 1
• Well-tolerated, though some patients experience nausea and sleep disturbances 1
• Significantly reduces overall neuropsychiatric symptoms, agitation, and depression in dementia patients 1

Sertraline

• Start at 25–50 mg daily, maximum 200 mg daily 1
• Well-tolerated with less effect on metabolism of other medications 1
• Requires 4–8 weeks for full therapeutic effect at adequate dosing 1

SSRIs have a substantially better safety profile than antipsychotics, without the increased mortality risk (1.6–1.7 times higher than placebo) associated with antipsychotic use in elderly dementia patients 1.

Monitoring SSRI Response

• Evaluate response within 4 weeks using quantitative measures such as the Cohen-Mansfield Agitation Inventory or Neuropsychiatric Inventory Questionnaire (NPI-Q) 1, 2
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 1
• Even with positive response, periodically reassess the need for continued medication 1

Second-Line: Antipsychotics (Only for Severe, Dangerous Aggression)

Reserve antipsychotics exclusively for situations where the patient is severely agitated, threatening substantial harm to self or others, and both behavioral interventions and an adequate SSRI trial have failed 1:

When to Consider Antipsychotics

• Severe agitation with psychotic features (hallucinations, delusions) 1
• Aggression causing imminent risk of harm to self or others 1
• Documented failure of non-pharmacological approaches after adequate trial 1
• Emergency situations with imminent danger 1

Risperidone (Preferred Antipsychotic)

• Start at 0.25 mg once daily at bedtime, target dose 0.5–1.25 mg daily 1
• Maximum 2–3 mg/day in divided doses 1
• Risk of extrapyramidal symptoms increases dramatically above 2 mg/day 1
• Most common side effects: somnolence (51%), sedation, weight gain (15–20%) 1

Alternative Antipsychotics

• 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—generally well-tolerated but less effective in patients over 75 years 1

Critical Safety Discussion Required

Before initiating 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) 1
• Cardiovascular effects: QT prolongation, dysrhythmias, sudden death, hypotension 1
• Cerebrovascular adverse reactions including stroke risk 1
• Falls risk and metabolic changes 1
• Expected benefits and treatment goals 1
• Alternative non-pharmacological approaches 1

Antipsychotic Monitoring and Duration

• 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—approximately 47% of patients continue receiving antipsychotics after discharge without clear indication 1
• Monitor for extrapyramidal symptoms, falls, sedation, metabolic changes, QT prolongation, and cognitive worsening 1

Medications to AVOID

Benzodiazepines

Do not use benzodiazepines for routine agitation management (except for alcohol or benzodiazepine withdrawal) 1:

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

Typical Antipsychotics (Haloperidol, Chlorpromazine)

• Avoid as first-line therapy—associated with 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 1
• Reserve haloperidol (0.5–1 mg) only for acute severe agitation with imminent risk of harm when rapid control is essential 1
• The WHO explicitly recommends against chlorpromazine for behavioral symptoms in dementia due to safety concerns 1

Anticholinergic Medications

• Identify and discontinue diphenhydramine, hydroxyzine, oxybutynin, cyclobenzaprine—these worsen confusion and agitation 1

Common Pitfalls to Avoid

• Do not continue antipsychotics indefinitely—review need at every visit and taper if no longer indicated 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
• Do not add medications without first treating reversible medical causes (pain, infection, metabolic disturbances) 1
• Do not skip non-pharmacological interventions unless in an emergency situation 1
• Do not use medications with significant anticholinergic effects as they worsen cognitive symptoms 4