From the Guidelines
Agitation in dementia should be managed primarily through non-pharmacological approaches, with a focus on maintaining a consistent routine, creating a calm environment, and addressing triggers, as recommended by the most recent guidelines 1. When considering management strategies for agitation in dementia, it's essential to prioritize non-pharmacological interventions. These may include:
- Maintaining a consistent routine
- Creating a calm environment
- Identifying and addressing triggers such as pain, hunger, fatigue
- Using redirection techniques
- Ensuring adequate sleep
If these non-pharmacological approaches are insufficient, medications may be considered. For mild to moderate agitation, SSRIs like citalopram (10-20mg daily) or sertraline (25-100mg daily) may be considered as a first-line treatment, as they have been shown to reduce overall neuropsychiatric symptoms, agitation, and depression in individuals with VCI 1. For more severe agitation, low-dose antipsychotics may be used short-term, such as risperidone (0.25-1mg daily), quetiapine (25-200mg daily), or olanzapine (2.5-10mg daily), though they carry black box warnings for increased mortality in elderly patients with dementia 1. It's crucial to use these medications at the lowest effective dose for the shortest duration possible, with regular reassessment. Agitation in dementia often stems from brain changes that affect emotional regulation and communication abilities, making patients frustrated when they cannot express needs or understand their environment. Non-pharmacological strategies, such as simulated presence therapy, massage therapy, animal-assisted interventions, and personally tailored interventions, can also be effective in reducing symptoms of agitation in individuals with severe dementia 1.
From the Research
Non-Pharmacological Interventions for Agitation in Dementia
- Non-pharmacological interventions are being increasingly implemented to manage agitation in people with dementia due to the adverse reactions and limited effectiveness of medications 2.
- A systematic review and Bayesian network meta-analysis found that massage therapy, animal-assisted intervention, and personally tailored intervention were associated with more substantial reductions in agitation compared to other interventions and controls 2.
- Another systematic review of randomised controlled trials found that person-centred care, communication skills training, and adapted dementia care mapping decreased symptomatic and severe agitation in care homes immediately and for up to 6 months afterwards 3.
- Activities and music therapy by protocol decreased overall agitation, and sensory intervention decreased clinically significant agitation immediately 3.
Pharmacological Interventions for Agitation in Dementia
- Acetylcholinesterase inhibitors and memantine should be initiated to enhance cognition, and if present, management of insomnia or sundowning with trazodone is indicated 4.
- Treatment with citalopram can be initiated with attention paid to potential prolongation of the QT interval, and treatment with low doses of atypical antipsychotics such as risperidone or quetiapine can be effective after appropriate consideration of and disclosure of potential adverse effects 4.
- A review of antidepressants for agitation and psychosis in dementia found that SSRIs were associated with a reduction in symptoms of agitation when compared to placebo, and both SSRIs and trazodone appear to be tolerated reasonably well when compared to placebo, typical antipsychotics, and atypical antipsychotics 5.
Effective Non-Pharmacological Interventions
- Music therapy was found to be the most effective non-pharmacological intervention for reducing agitation/aggressive behaviour in people with dementia, followed by aromatherapy and massage, and finally physical exercise 6.
- Aromatherapy and light therapy did not demonstrate efficacy in reducing agitation in dementia 3.
- Person-centred care, communication skills training, and adapted dementia care mapping were found to be effective in decreasing symptomatic and severe agitation in care homes 3.