In an 86‑year‑old male with dementia and severe agitation who is currently receiving bromperidol 75 mg twice daily in a memory‑care unit, what pharmacologic options are appropriate?

Management of Severe Agitation in an 86-Year-Old Male with Dementia

Immediate Action: Stop Bupropion and Investigate Medical Causes

You must discontinue the bupropion 75 mg BID immediately—this medication is contraindicated in dementia patients and likely worsening his agitation. Bupropion lowers seizure threshold (especially concerning when combined with other psychotropics), has no role in treating dementia-related agitation, and its stimulant properties can paradoxically increase behavioral disturbances 1.

Before adding any medication for agitation, systematically rule out and treat reversible medical triggers that are disproportionately common in this population 1:

• Pain assessment—a major contributor to agitation in patients who cannot verbally communicate discomfort 1
• Infections—check urinalysis/culture for UTI and evaluate for pneumonia, as these are common precipitants 1
• Metabolic disturbances—dehydration, electrolyte abnormalities, hypoxia, constipation, urinary retention 1
• Medication review—identify and discontinue any anticholinergic agents (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen confusion 1

Non-Pharmacological Interventions (Mandatory First-Line)

Implement these evidence-based strategies before considering any psychotropic medication 1:

• Environmental modifications: Ensure adequate lighting (especially late afternoon), reduce excessive noise, provide predictable daily routines 1
• Communication strategies: Use calm tones, simple one-step commands, gentle touch for reassurance; allow adequate processing time 1
• Structured activities: At least 30 minutes of daily sunlight exposure, supervised physical/social activities tailored to his abilities 1
• Caregiver education: Staff must understand that agitation is a symptom of dementia, not intentional behavior 1

Pharmacological Treatment Algorithm

For Chronic Moderate-to-Severe Agitation: SSRIs Are First-Line

If behavioral interventions fail after 2–4 weeks and agitation remains moderate-to-severe, initiate an SSRI as your first pharmacological choice 1:

• Sertraline 25–50 mg once daily (preferred due to minimal drug interactions and excellent tolerability) 1

  • Titrate by 25–50 mg increments weekly as needed
  • Maximum dose: 200 mg/day
  • Assess response at 4 weeks using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) 1
  • If no clinically significant improvement after 4 weeks at adequate dosing, taper and discontinue 1

• Alternative: Citalopram 10 mg once daily (maximum 40 mg/day), though some patients experience nausea and sleep disturbances 1

SSRIs significantly reduce overall neuropsychiatric symptoms, agitation, and depression in dementia patients, with substantially lower risk than antipsychotics 1.

For Severe Acute Agitation with Imminent Risk of Harm: Low-Dose Antipsychotics

Reserve antipsychotics only when the patient is severely agitated, threatening substantial harm to self or others, and SSRIs/behavioral approaches have failed 1:

• Risperidone 0.25 mg once daily at bedtime (first-line antipsychotic choice) 1, 2

  • Increase by 0.25 mg increments every 5–7 days as tolerated
  • Target dose: 0.5–1.25 mg daily
  • Maximum: 2 mg/day (extrapyramidal symptoms increase dramatically above 2 mg) 1

• Alternative: Quetiapine 12.5 mg twice daily (more sedating, useful for sundowning) 1, 3

  • Titrate slowly to maximum 200 mg twice daily
  • Monitor for orthostatic hypotension and falls 3

Critical Safety Discussion Required Before Any Antipsychotic

You must discuss with the patient's surrogate decision-maker before initiating any antipsychotic 1, 4:

• Increased mortality risk: 1.6–1.7 times higher than placebo in elderly dementia patients 1, 4
• Cardiovascular risks: QT prolongation, dysrhythmias, sudden death, hypotension 1
• Cerebrovascular events: Increased stroke risk 4
• Falls, metabolic changes, extrapyramidal symptoms 1

Duration and Monitoring

• Use the lowest effective dose for the shortest possible duration 1
• Daily in-person examination to evaluate ongoing need and assess for side effects 1
• Attempt taper within 3–6 months to determine if still needed—approximately 47% of patients continue antipsychotics after discharge without clear indication 1
• Monitor for: extrapyramidal symptoms, falls, sedation, metabolic changes, QT prolongation, cognitive worsening 1

What NOT to Use

• Benzodiazepines (lorazepam, alprazolam)—increase delirium incidence/duration, cause paradoxical agitation in ~10% of elderly patients, risk respiratory depression 1

  • Exception: alcohol or benzodiazepine withdrawal 1

• Typical antipsychotics (haloperidol, chlorpromazine) as first-line—50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 1

  • Haloperidol 0.5–1 mg may be considered only for severe acute agitation with imminent danger, maximum 5 mg/day 1

• Cholinesterase inhibitors should not be newly prescribed for agitation—associated with increased mortality 1

Common Pitfalls to Avoid

• Do not add medications without first treating reversible medical causes (pain, infection, metabolic issues) 1
• Do not continue antipsychotics indefinitely—review need at every visit and taper promptly 1
• Do not use antipsychotics for mild agitation or behaviors like unfriendliness, poor self-care, repetitive questioning, or wandering 1
• Do not combine high-dose benzodiazepines with antipsychotics—risk of fatal respiratory depression 1