Medication Management for Behavioral Symptoms in Elderly Patients with Dementia/Parkinson's Disease

Critical First Principle: Non-Pharmacological Interventions Must Come First

Non-pharmacological interventions are mandatory first-line treatment and must be systematically attempted and documented as failed before any medication is considered, unless there is imminent risk of harm to self or others 1

Pain assessment and management is the single most common contributor to behavioral disturbances 1, 2
Infections, such as urinary tract infections and pneumonia, should be aggressively investigated and treated 1, 2
Metabolic disturbances, including dehydration, constipation, urinary retention, and hypoxia, should be identified and addressed 1
Medication review should identify and discontinue all anticholinergic agents that worsen confusion and agitation 1, 2
Sensory impairments, such as hearing and vision problems, should be assessed and addressed to reduce confusion and fear 1

Communication strategies, including calm tones, simple one-step commands, and gentle touch, should be used to reassure patients 1, 3
Environmental modifications, such as ensuring adequate lighting and reducing excessive noise, should be implemented to reduce agitation 1, 3
Safety measures, including installing grab bars and removing hazards, should be taken to prevent falls 3
ABC charting should be used to document antecedents, behaviors, and consequences to identify specific triggers 1

Medications should only be used in specific circumstances, such as severe agitation, psychosis, major depression, or aggression, after non-pharmacological approaches have been thoroughly attempted 1, 2

SSRIs, such as citalopram and sertraline, are first-line pharmacological treatment for chronic agitation in dementia and Parkinson's disease 1
Risperidone is the preferred first-line antipsychotic for severe behavioral symptoms in dementia 1
Quetiapine or clozapine are the only safe antipsychotic options for Parkinson's disease psychosis 1

Before initiating any antipsychotic, the patient and surrogate decision maker must be informed of the increased mortality risk, cardiovascular effects, cerebrovascular adverse reactions, falls risk, metabolic effects, and expected benefits and treatment goals 1
Benzodiazepines should not be used as first-line treatment for agitated dementia, except for alcohol or benzodiazepine withdrawal 1
Typical antipsychotics should not be used as first-line therapy for chronic agitation due to the risk of tardive dyskinesia 1
Anticholinergic medications should be discontinued as they worsen agitation and cognitive function 1, 2

Evaluate response within 4 weeks using quantitative measures, such as the Cohen-Mansfield Agitation Inventory or NPI-Q 1
Daily in-person examination should be conducted to assess ongoing need when using antipsychotics 1
Monitor for side effects, including extrapyramidal symptoms, falls, sedation, metabolic changes, QT prolongation, and cognitive worsening 1
Use the lowest effective dose for the shortest possible duration and attempt taper within 3-6 months 1

Do not continue antipsychotics indefinitely without regular reassessment 1
Do not use antipsychotics for mild agitation, reserve for severe, dangerous symptoms 1
Do not underestimate pain and discomfort as causes of behavioral symptoms in patients who cannot verbally communicate 1, 2
Do not rely solely on medications without implementing non-pharmacological strategies 3
Do not add medications without first reviewing and deprescribing unnecessary agents contributing to polypharmacy 4