From the Guidelines
Agitation in elderly dementia patients should be managed with a stepwise approach, beginning with non-pharmacological interventions before considering medications, as recommended by the most recent guidelines 1, 2. The first step in managing agitation in elderly dementia patients is to identify and address potential triggers such as pain, hunger, thirst, constipation, infection, or environmental factors like noise or unfamiliar surroundings.
- Establish consistent routines, provide reassurance, use distraction techniques, and create a calm environment.
- Music therapy, reminiscence activities, and gentle physical exercise can also help reduce agitation, as suggested by recent studies 2. If medications become necessary, the choice of medication should be based on the most recent and highest quality evidence, which suggests that SSRIs are considered first-line treatments for agitation in patients with dementia 2.
- Start with low doses of SSRIs such as citalopram (10-20mg) or sertraline, titrating slowly while monitoring for side effects.
- Alternative medications include trazodone (25-50mg) or mirtazapine (7.5-15mg) for agitation with depression or anxiety.
- Antipsychotics, such as quetiapine, risperidone, or olanzapine, should be used with caution due to the increased risk of mortality in elderly dementia patients, as highlighted by previous guidelines 3, 4. Regular medication reviews are essential to minimize unnecessary psychotropic use and to ensure that the benefits of medication outweigh the risks.
- The underlying neurodegeneration in dementia affects neurotransmitter systems, particularly acetylcholine, dopamine, and serotonin, contributing to behavioral symptoms that may require both environmental and pharmacological management.
- It is also important to consider the patient's quality of life, caregiver burden, and the potential impact of medication on these factors, as emphasized by recent studies 1, 2.
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 answer the question about agitation in the elderly dementia.
From the Research
Agitation in Elderly Dementia
- Agitation is a common symptom among older adults with dementia, with a prevalence ranging from 30 to 50% in Alzheimer's disease and other types of dementia 5.
- The origin of agitation in dementia is often multi-factorial and can be difficult to treat 6.
- Factors that can precipitate agitation in dementia patients include sundown syndrome, hospitalization, admission to nursing residencies, changes in pharmacological regimens, and environmental factors such as low lighted environments 5.
Pharmacological Management
- The choice of pharmacological options for managing agitation in dementia depends on patient comorbidities, specific symptoms, and patient tolerance of medications 6.
- Low- to moderate-quality evidence supports the use of anti-depressants, anti-psychotics, or anti-epileptics in conjunction with cholinesterase inhibitors for managing behavioral and psychological symptoms of dementia (BPSD) 6.
- Atypical antipsychotics may be effective for short-term management of severe agitation, but their use is associated with significant risks and should be carefully considered 7.
- Other medications, such as acetylcholinesterase inhibitors, memantine, and citalopram, may also be effective for managing agitation in dementia 8.
Non-Pharmacological Interventions
- Non-pharmacological interventions, such as person-centered care, communication skills training, and adapted dementia care mapping, can be effective for reducing symptomatic and severe agitation in care homes 9.
- Activities and music therapy, as well as sensory intervention, may also be beneficial for reducing overall agitation and clinically significant agitation 9.
- Aromatherapy and light therapy have not been shown to be effective for managing agitation in dementia 9.
Prevention and Treatment Strategies
- Identifying and addressing medical and environmental precipitants of agitation is a priority in managing agitation in dementia 8.
- A comprehensive biopsychosocial assessment and treatment plan is likely the most effective way to manage agitation in dementia 7.
- Considering the heterogeneity of patients and their comorbidities, as well as the specific nature of their agitation, there is no "one-size fits all" approach to managing agitation in dementia 8.