Medication For Agitation And Irritability In Dementia

According to research, “approximately 90% of people with dementia exhibit agitated behaviors, sleep disturbances, and other psychiatric symptoms.” Agitation is described as “a behavioral syndrome characterized by increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress.”

Agitation can take a toll on both the quality of life of the person with dementia and their family. Knowing how to manage these behaviors is key to supporting the wellbeing of the person with dementia and their family at home. Helpful strategies include behavior techniques, changes to the environment, and, when needed, medication.

This article focuses on pharmacologic ways to address agitation in dementia. For more strategies on managing agitation, confusion, and irritability in dementia, check if you have free access to Trualta. 

When Should You Use Medication to Manage Agitation? 

Starting medication for agitation in dementia should be a last resort. Before jumping straight to medication, it’s recommended to try non-medical interventions first. 

There are many first-line treatment strategies for managing agitation in individuals with dementia, including: 

• Behavioral interventions like calming music or a comforting TV show
• Identifying and addressing possible triggers (like hunger or lack of sleep) 
• Adjusting the environment to promote calmness and serenity
• Exercise and physical activity
• Emphasis on familiar routines and structure during the day

If you have exhausted all non-pharmacologic interventions, it may be time to consider medication. It’s wise to consider initiating medication if any of the following happen: 

• Non-pharmacological interventions fail 
• Agitation is persistent, consistent, and severe.
• If the agitation begins to pose a safety risk to the care recipient or others
• Agitation behaviors lead to hospitalizations 

Medications For Individuals With Dementia Agitation

Several types of medications may be prescribed to help manage agitation in people with dementia. These include antipsychotics, antidepressants, and cholinesterase inhibitors. Each type works differently, comes with its own risks and benefits, and should be carefully considered with a healthcare provider.

Antipsychotics 

Antipsychotics are “a type of drug for those who have severe agitation and distress from psychotic symptoms like hallucinations and delusions.” Antipsychotics are powerful drugs that should be carefully monitored and dosed by a medical professional. 

How they work: This class of drugs has been shown to help with aggressive and agitated behaviors. Antipsychotics work by sedating and calming the individual. They also may help decrease the frequency of hallucinations and paranoia. 

Considerations: They are often used as a last resort. Because they’re so strong, it’s recommended to have your doctor review the effect of the drug after 6 weeks or 12 weeks of taking it. 

The type of antipsychotic used may depend on your care recipient’s specific dementia diagnosis. For example, Resperidone (Risperdal), may be used for Alzheimer’s-related psychosis. Talk to your care recipient’s doctor about what would work best for them. 

Side effects of antipsychotics are serious. The FDA recommends a “black box” label warning on antipsychotics as they have significant side effects and should be used with caution and under the monitoring of a doctor or pharmacist. Side effects include:

• Stroke 
• Drowsiness 
• Shakiness
• Risk of falls
• Impaired balance 
• Death

Antidepressants

Antidepressants are sometimes prescribed for people with dementia who exhibit irritability and aggression. Depression is often an underdiagnosed symptom of dementia and could explain why the person you care for might be irritable, withdrawn, or easily agitated. 

How they work: Antidepressants increase neurotransmitters in the brain, including norepinephrine and serotonin. 

Considerations: There is mixed research on the effectiveness of antidepressants on aggression and agitation in dementia. This type of drug is most appropriate for people with dementia who have an added layer of depression on top of their diagnosis. Pay attention to your care recipient. If they’re showing signs of withdrawal or low mood, as well as agitation, talk to a doctor about this medication.

Types of antidepressants used for people with dementia: 

• For insomnia and depressive symptoms:
  • Mirtazapine
• For general depressive symptoms and to preserve cognitive function:
  • Citalopram
  • Sertraline
  • Low-dose venlafaxine
  • Vortioxetine (Trintellix)

Side effects of certain antidepressants may include: 

• Increased risk of falls
• Irregular heartbeat

Important: Some types of antidepressants, antipsychotics, antibiotics for respiratory or urinary tract infections, blood pressure medications, antifungals, and cancer medications can cause a heart condition called “QTc prolongation”. This puts patients at risk for a type of arrhythmia that can be fatal, called “torsades de pointes”. Talk to your care recipient’s doctor about these risks.

Cholinesterase Inhibitors 

Cholinesterase inhibitors are a class of drugs that have variable evidence in treating agitation in dementia. These are not first-line treatments for agitation, but may be used if other medications aren’t effective.

How they work: These drugs prevent the breakdown of acetylcholine, increasing its levels in the brain. This improves communication between neurons and improves cognitive function. 

Considerations: Individuals with increased delusions, hallucinations, irritability, and agitation are more likely to respond well to the use of this type of medication.

Types of cholinesterase inhibitors: 

• Donepezil (Aricept)
• Rivastigmine (Exelon)
• Galantamine (Razadyne)

Side effects: This type of drug is usually well tolerated; however, if side effects occur, people often present with: 

• Dizziness
• Headache
• Nausea
• Loss of appetite
• Vomiting or gastrointestinal distress

Guiding Principles When Starting Medication

Starting medication for a loved one with dementia is a serious decision that should be made with care. It involves weighing their medical needs, behaviors, and overall quality of life. If you’re considering medication to manage agitation or aggression, there are several important factors to discuss with a healthcare provider.

Here are some tips: 

• Know who makes the decision: Individuals with dementia, especially in later stages, often cannot consent for themselves. If you are their substitute decision maker, you’ll need to work with the doctor to decide whether to start medication.
• Understand the risks and benefits: Ask questions to learn what the medication is intended to do, along with possible side effects and long-term impacts. This way, you can make an informed decision for each concern. 
• Start low, go slow: Begin with a low dose as prescribed, and increase only if needed under medical supervision. Don’t change a dose on your own.
• Watch for interactions: Be aware of any other medications your loved one takes, and monitor for potential drug-to-drug interactions.
• Monitor closely: Regularly reassess their response to the medication to ensure it remains safe and effective.
• Consider tapering if possible: If symptoms improve, ask your doctor whether your loved one might eventually reduce or stop the medication.

Conclusion

Managing aggression, agitation, and irritability is a key part of dementia care. It takes a combination of strategies and a good understanding of what works best in their case. By collaborating with their medical team, starting medication carefully, and monitoring closely, you can help reduce behaviors you have difficulty managing and support a calmer, more comfortable quality of life.

References 

1. Alzheimer’s Association. (n.d.). Treatments for behavior. 
2. Alzheimer’s Association. (n.d.). Medications for memory.
3. Alzheimer’s Society. (n.d.). Antipsychotic drugs and other approaches for dementia. 
4. Ballard, C., Waite, J., Birks, J., & Kalaria, R. (2006). Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database of Systematic Reviews, 2006(1), CD003476.
5. Ismail, Z., Elbayoumi, H., Fischer, C. E., Hogan, D. B., Millikin, C. P., Schweizer, T., … & Mortby, M. E. (2021). Neuropsychiatric symptoms as early manifestations of emergent dementia: Provisional diagnostic criteria for mild behavioral impairment. Frontiers in Neurology, 12, 644317.
6. Jones, E., Aigbogun, M. S., Pike, J., Berry, M., Houle, C. R., & Husbands, J. (2021). Agitation in dementia: Real-world impact and burden on patients and the healthcare system. Journal of Alzheimer’s Disease, 83(1), 89–101.
7. Rosenberg, P. B., Mielke, M. M., & Lyketsos, C. G. (2024). Agitation in Alzheimer disease: Epidemiology, pathophysiology, and treatment. JAMA Neurology.
8. Schneider, L. S., Dagerman, K. S., & Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. JAMA, 294(15), 1934–1943.