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Treatment of Agitation and Psychosis in Alzheimer's Disease

The following treatment guidelines are meant as a reference tool, but are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

Psychosis and agitated or aggressive behavior are common problems in Alzheimer's Disease and other forms of dementia [ref], and pose some of the greatest challenges to caregivers. While psychosis and agitation are separate problems, psychosis can also lead to agitated and aggressive behavior in certain cases.

Non-medication approaches

The preferred option for managing these issues is without medications. There are several therapeutic interventions that have been shown to be effective for moderating disruptive behaviors [ref].

  • Behavioral management techniques, based on Behavioral Therapy, remain effective up to several months after the intervention. Teaching these techniques to care-takers can be helpful.
  • Music therapy can foster calmness and reduce disruptive behaviors during and shortly after sessions. Calm background music, such as classical music, can also be helpful
  • It is important to make the individual's surroundings as pleasant and familiar as possible. Keep photos of family members and good friends nearby. Decorate spaces tastefully, with calm colours, plants, and pleasant artwork. In nursing homes and other institutions, it is important to assign a limited number of staff caretakers and workers for any given resident, and to avoid changing a resident's staff as much as possible.

Unfortunately, these approaches are not always effective or even feasible for preventing agitation or psychosis. For this reason, medications are often used.

Antipsychotic medications

Antipsychotics have traditionally been the most commonly prescribed medications for these problems. However, it has been discovered that these medications also carry an increased risk of mortality when used in individuals with dementia [ref, ref]. This is thought to arise from causes such as penumonia, thrombo-embolic events (which can lead to strokes and heart attacks), and cardiac arrhythmias (which can also lead to heart attacks) [ref].

These medications are thus to be used in individuals with dementia only when absolutely needed, and for limited amounts of time. Psychosis and agitation can often be transient problems in dementia, and so the need for continuing antipsychotic medication should be frequently re-evaluated.

Among the antipsychotics, Quetiapine has been shown to have the lowest rate of increased mortality when used in individuals with dementia [ref]. Risperidone, Olanzapine and Abilify seem to have higher rates, while Haloperidol has been shown to have the highest risk in this regard [ref].

On the other hand, Quetiapine seems to be less effective than the other antipsychotics for controlling psychosis and agitation in dementia [ref]. Risperidone and Olanzapine have been found in several studies to be reasonably effective [ref].

SSRI antidepressants

SSRI antidepressants have also been used to control agitation in individuals with Alzheimer's Disease [ref]. One large study recently confirmed that Citalopram used at standard doses is quite effective for this purpose [ref]. Furthermore, SSRIs do not seem to pose the same health risks for individuals with dementia as do the antipsychotics.

Other medications

Valproic Acid (in very low doses starting at 125mg once or twice a day) [ref], Carbamazepine (at doses of about 300mg per day) [ref], and Memantine in combination with Donepezil [ref], all have some evidence to suggest that they are effective in controlling behavioral disturbances in Alzheimer's Disease and with reasonable side-effect profiles.

In situations where acute agitation needs to be quickly controlled, Benzodiazepines could be considered [ref, ref].

General treatment guideline for psychosis and agitation in dementia

To summarize the above information, a general treatment guideline for treating psychosis or agitation in the context of dementia would be as follows (proceed to each next step only if the symptoms have not resolved):

  1. Put in place all available non-medication options.
  2. Try Citalopram at 10-20mg daily (though if the problem is more purely psychosis, and not much in the way of agitation, skip this step)
  3. Add, or replace with, Quetiapine, regular or XR format, in the range of 25-100mg daily.
  4. Replace Quetiapine with low-dose Risperidone or Olanzapine.
  5. Try any of the following:

Cognitive and Functional Loss

Depression