What medication is used to improve agitation in dementia patients? An expert guide

Nearly 80% of people with dementia will experience agitation at some point, a symptom that can significantly distress both the patient and their caregivers. Answering the question, "What medication is used to improve agitation in dementia patients?" is complex, as it involves weighing efficacy against serious risks, with non-drug approaches as the primary strategy. This guide explores the options for pharmacological management.

Quick Summary

Brexpiprazole (Rexulti) is the only FDA-approved medication for agitation associated with Alzheimer's dementia. However, non-pharmacological interventions are the recommended first line of treatment, with other medications, such as antipsychotics and antidepressants, sometimes used off-label but carrying significant risks.

Key Points

• FDA-Approved Medication: Brexpiprazole (Rexulti) is the only drug with FDA approval specifically for agitation related to Alzheimer's dementia, but carries serious warnings.

• First-Line Approach: Non-pharmacological interventions, such as music therapy, routine maintenance, and environmental changes, should always be attempted first to manage agitation.

• Significant Risks: Most medications used for agitation, particularly antipsychotics, have a "black box" warning due to an increased risk of death in older adults with dementia-related psychosis.

• Personalized Care: The most effective treatment plan involves understanding the individual triggers for agitation and tailoring a comprehensive strategy that prioritizes the patient's well-being.

• Caregiver Education: Caregivers play a critical role in managing agitation by creating a calm environment, using redirection, and maintaining a patient-centered mindset.

Understanding Agitation in Dementia

Agitation in dementia patients can manifest in various ways, from restlessness and pacing to verbal and physical aggression. It is often a sign that the individual is distressed, confused, or struggling to communicate a need. Identifying and addressing the underlying cause is the most effective approach, and medication is typically considered only after non-drug methods have been exhausted. These behaviors are not intentional and should be managed with compassion and a person-centered approach.

The FDA-Approved Option: Brexpiprazole (Rexulti)

In 2023, the U.S. Food and Drug Administration (FDA) made a significant move by approving brexpiprazole (Rexulti) specifically for the treatment of agitation associated with dementia due to Alzheimer's disease. This was the first medication to receive such an indication. As an atypical antipsychotic, brexpiprazole works by affecting serotonin and dopamine pathways in the brain. However, it's critical to note the context of its approval and use:

• Targeted Use: It is specifically for agitation associated with Alzheimer's and is not approved for broader dementia-related psychosis.
• Black Box Warning: Like all atypical antipsychotics, Rexulti carries a "black box" warning regarding an increased risk of death in older patients with dementia-related psychosis. This serious warning means a doctor must carefully evaluate the benefits against the risks for each individual patient.
• Part of a Comprehensive Plan: Even with an FDA-approved option, healthcare providers emphasize that medication should be part of a broader, personalized care strategy.

First-Line Strategies: Non-Pharmacological Interventions

Before considering any medication, experts and organizations like the Alzheimer's Association strongly recommend a non-pharmacological approach. These strategies focus on identifying triggers and modifying the environment to reduce distress.

Environmental and Routine Adjustments

• Create a calm environment: Reduce noise, glare, and clutter. A predictable and structured daily routine can significantly reduce anxiety.
• Adjust lighting: Specifically, during the late afternoon and evening, known as "sundowning," using more natural light exposure during the day and tailored lighting at night can help regulate sleep cycles and decrease agitation.
• Ensure comfort: Check for basic needs like pain, hunger, thirst, or discomfort from a full bladder or constipation. The temperature of the room can also be a factor.

Activity and Engagement

• Meaningful activities: Engage the person in simple, enjoyable tasks, such as folding laundry, listening to favorite music, or looking at family photos.
• Physical activity: A walk or light physical exercise can help burn off restless energy.
• Distraction and redirection: Gently steer the person's attention away from the source of agitation towards a more positive activity.

Other Medications and Their Associated Risks

While brexpiprazole is the only FDA-approved medication, other drug classes are sometimes used off-label to manage severe agitation. This should be done with extreme caution due to the significant risks involved, particularly in older adults.

Antipsychotics (Off-Label Use)

• Examples: Risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel).
• Risks: These medications also carry the black box warning for increased mortality and stroke risk. They can cause sedation, movement disorders, and other adverse effects. Use is typically limited to cases where agitation is severe and presents a danger to the patient or others, and for a short duration.

Antidepressants (Off-Label Use)

• Examples: Selective serotonin reuptake inhibitors (SSRIs) like citalopram (Celexa) and sertraline (Zoloft), or trazodone.
• Risks: Citalopram, while potentially effective for agitation, can cause side effects at higher doses, including a higher risk of falls and heart rhythm issues. These are used primarily if agitation is thought to be linked to depression or anxiety.

Anti-Anxiety Medications (Off-Label Use)

• Examples: Lorazepam (Ativan), oxazepam (Serax).
• Risks: Benzodiazepines are generally discouraged due to the risk of increased confusion, sedation, and falls, which can paradoxically worsen agitation in some dementia patients. They are typically reserved for short-term, acute situations.

Comparison of Pharmacological Approaches

Medication Class	FDA-Approved Indication (Dementia)	Key Context for Agitation	Major Risks (Black Box Warning)
Atypical Antipsychotics (Brexpiprazole)	Yes (Agitation in Alzheimer's Dementia)	The only approved option; still requires careful consideration and monitoring.	Increased risk of death in older patients with dementia-related psychosis.
Atypical Antipsychotics (Off-Label)	No	Off-label use for severe, dangerous agitation after other options fail.	Increased risk of death in older patients with dementia-related psychosis, stroke, etc.
Antidepressants (Off-Label)	No	Used when agitation is linked to underlying mood disorders like depression or anxiety.	Variable risks, including increased falls and cardiovascular issues with citalopram.
Anti-Anxiety Medications (Off-Label)	No	Short-term, acute use only for severe distress; generally not recommended for long-term management.	Increased confusion, sedation, fall risk; can worsen agitation.

A Caregiver’s Practical Guide to Managing Agitation

Caring for someone with dementia can be challenging, but understanding and implementing effective strategies can make a significant difference. Here are actionable tips for caregivers:

1. Be a detective. Keep a log of when agitation occurs, what happens, and what was happening immediately before. Look for patterns and triggers.
2. Ensure needs are met. Start with the basics. Are they hungry? In pain? Overstimulated? These are common drivers of agitated behavior.
3. Use redirection. Gently guide their focus away from the source of distress. For example, if they are pacing anxiously, suggest a quiet walk or a cup of tea.
4. Communicate calmly. Use simple, clear language. Avoid arguing or raising your voice, which can escalate the situation. Reassure them that they are safe.
5. Lean on non-drug therapies. Explore options like music therapy, which has been shown to reduce agitation in dementia patients. Learn more about effective non-pharmacological approaches from trusted sources like the Alzheimer's Association.
6. Consult with a doctor. Never start, stop, or change a medication without a healthcare provider's guidance. Discuss all options, including risks and benefits, and prioritize non-drug approaches.

Conclusion: A Person-Centered and Cautious Approach

When asking what medication is used to improve agitation in dementia patients? the answer is not a simple prescription but a process. While brexpiprazole offers a new, FDA-approved tool for specifically managing agitation in Alzheimer's, it, and other off-label options, must be used judiciously due to significant risks. The cornerstone of care for dementia-related agitation remains a person-centered approach focused on non-pharmacological strategies, environmental modifications, and consistent routines. A collaborative and cautious approach with a healthcare provider is essential to ensure the safety and well-being of the patient.

Frequently Asked Questions

Is brexpiprazole the only medication that can be used for dementia agitation?

Brexpiprazole (Rexulti) is the only medication with specific FDA approval for agitation associated with Alzheimer's dementia. Other medications, including some antipsychotics and antidepressants, are sometimes used "off-label" but carry significant risks and are not recommended as a first option.

Why do antipsychotics carry a black box warning for dementia patients?

Antipsychotics carry a black box warning because studies have shown they increase the risk of death in older adults with dementia-related psychosis. The causes of death can include stroke, heart failure, and infections like pneumonia.

What are some non-drug ways to manage agitation in dementia?

Effective non-drug strategies include identifying and addressing triggers, creating a calm and predictable environment, using distraction and redirection techniques, incorporating music or art therapy, and ensuring the patient's basic needs are met.

When should medication be considered for dementia agitation?

Medication should be considered as a last resort when non-pharmacological interventions have been unsuccessful, and the agitation is severe, persistent, and causing significant distress or posing a danger to the patient or others.

Can agitation in dementia be a sign of another medical issue?

Yes. Agitation can be caused by underlying medical issues such as pain, an infection (like a UTI), dehydration, or medication side effects. It's important for a doctor to perform a full evaluation to rule out these possibilities before starting or escalating treatment for agitation.

How can caregivers safely administer and monitor medication for agitation?

Caregivers should strictly follow a healthcare provider's instructions, monitor for side effects, and report any concerning changes immediately. Close observation is crucial, and the medication should be given at the lowest effective dose for the shortest possible duration.

Does medication cure agitation in dementia patients?

No. Medication is used to manage and reduce symptoms, not cure the underlying dementia or the agitation itself. It should always be used as one component of a broader, personalized care plan.