Agitation Associated with Dementia Due to Alzheimer’s Disease

Agitation Associated with Dementia Due to Alzheimer’s Disease – Treatment Options

Introduction
Agitation is one of the most challenging behavioral and psychological symptoms of dementia (BPSD), especially in Alzheimer’s disease. It may manifest as restlessness, pacing, shouting, verbal/physical aggression, or resistance to care. Agitation can worsen disease progression, increase caregiver burden, and often leads to institutionalization. Treatment focuses first on non-pharmacological strategies, with medications reserved for cases where behaviors cause distress or pose a safety risk.

---

1. Non-Pharmacological Interventions (First-Line)

• Environmental modifications: Reduce noise, improve lighting, and maintain structured routines.

• Reorientation and reassurance: Use calendars, clocks, and familiar objects to reduce confusion.

• Engagement in activities: Music therapy, reminiscence therapy, and gentle exercise can reduce agitation.

• Caregiver education: Training in communication strategies and handling behavioral outbursts.

• Address unmet needs: Ensure adequate pain management, hydration, nutrition, toileting, and sleep hygiene.

---

2. Pharmacological Management (When Non-Drug Approaches Fail or Danger Exists)

• Antipsychotics (short-term use, lowest effective dose, monitor closely):

  • Risperidone (0.25–2 mg/day): FDA-approved in some regions for aggression in Alzheimer’s dementia.

  • Olanzapine, quetiapine, aripiprazole: Used off-label for agitation.

  • Risks: Extrapyramidal symptoms, sedation, increased stroke and mortality risk in elderly dementia patients.

• Antidepressants:

  • Citalopram (10–20 mg/day): Some evidence for reducing agitation with fewer side effects than antipsychotics.

  • Sertraline may also help when agitation is linked to depression or anxiety.

• Mood stabilizers (less evidence):

  • Valproate, carbamazepine – sometimes used, but limited by tolerability and safety concerns.

• Benzodiazepines (short-term only):

  • Lorazepam (0.25–0.5 mg): For acute severe agitation or anxiety, but risk of sedation, falls, and worsening cognition limits chronic use.

• Cholinesterase inhibitors and memantine:

  • May modestly reduce behavioral symptoms while improving cognition.

---

3. Emergency Management of Severe Agitation

• If the patient poses immediate danger to self or others:

  • Short-acting IM antipsychotic (e.g., haloperidol 0.5–1 mg) or lorazepam 0.25–0.5 mg may be given.

  • Continuous monitoring for oversedation, falls, or cardiac arrhythmias (especially QT prolongation).

---

4. Long-Term Supportive Care

• Regular medication review: Minimize polypharmacy and discontinue ineffective drugs.

• Ongoing caregiver support: Counseling, respite care, and support groups.

• Structured daily routines: Predictability helps reduce triggers of agitation.

• Regular reassessment: Behavioral symptoms often fluctuate; treatments should be individualized and adjusted over time.